Living with multiple chronic conditions presents significant challenges for both people and healthcare systems. It requires comprehensive, co‑ordinated, and continuous care, ideally provided by primary care to address the physical, mental, and social impacts. PaRIS data show that 82% of primary care users aged 45+ live with at least one chronic condition, and more than half have two or more. People with multiple conditions experience a worse quality of life and take multiple medications. Around 70% of these individuals use at least three medications regularly, with over a third using four or more, increasing the risk of patient safety issues and complex self-management. The type of chronic conditions also matters; mental health conditions alongside other chronic diseases worsen outcomes and experiences. This chapter highlights the vital role of primary care in supporting patients with multiple chronic conditions through interventions such as self-care, care co‑ordination, communication, and medication reviews.
Does Healthcare Deliver?
Abstract
What PaRIS data tell us about people living with multiple chronic conditions
While healthcare policy, research, professional training and clinical guidelines have traditionally focused on single diseases, PaRIS results stress that multimorbidity – people living with two or more chronic conditions – is a massive challenge in healthcare, particularly in primary care. As people live longer, they might increasingly live with (multiple) chronic conditions. More than half (54%) of the adults in PaRIS live with at least two chronic conditions, and about three out of ten (29%) with three or more. Multimorbidity is now the norm rather than the exception and has become the core business of many primary care professionals. Managing these conditions is far more complex and resource‑intensive than dealing with a single illness, putting pressure on healthcare systems and healthcare professionals to deliver high-quality, co‑ordinated, people‑centred care. These findings highlight the need for a shift from disease‑specific approaches to more people‑centred care.
Living with multiple chronic conditions often means taking numerous medications, creating significant challenges and risks for patients. The more conditions a person has, the more complex and riskier their medication regimen becomes. This increases the likelihood of medication safety incidents and makes self-management more complex. Among people with multiple chronic conditions in PaRIS, over 65% take at least three different medications on a regular or ongoing basis, and more than 30% take four or more. These findings highlight the urgent need for safer, more co‑ordinated care for people managing multiple conditions and for better collaboration between patients and healthcare professionals such as family doctors, pharmacists, nurses and other specialists.
People living with multiple chronic conditions have a lower quality of life. PaRIS data show that in all countries, people with two chronic conditions report worse physical and mental health, and fewer of them report good social functioning than people with one chronic condition. People with three or more chronic conditions have even worse health and fewer report having good social lives. While there are large differences in how people report their social lives in relation to the number of chronic conditions, these differences are not observed in physical and mental health.
Mental health is a critical factor in the management of multiple chronic conditions, and its impact on people’s social lives requires greater attention. People living with both a mental health condition and another chronic condition report poorer physical health. This pattern is consistent across countries. However, people with multiple chronic conditions are more likely to report good social functioning if they do not have a mental health condition compared to those who do. This difference highlights the importance of integrating mental health care and social support into chronic disease management in primary care. By addressing both physical and mental health together, and co‑ordinating social care, healthcare systems can manage patients with multiple chronic conditions more effectively and improve overall outcomes.
Well-designed primary care has the potential to improve the health and quality of life of people with multiple chronic conditions. Primary care plays a crucial role in managing the care for people with chronic conditions, making it a natural setting for implementing strategies and interventions to improve care co‑ordination, such as medication reviews and self-management support. PaRIS results show that people with multiple chronic conditions experience better co‑ordination of care when they have had a medication review, which means that they discussed with a healthcare professional all the medication that they take. This relationship is even more prominent among people with three or more chronic conditions. About 70% of people with multiple chronic conditions report that they had a medication review over the past year. This varies widely across countries from over 85% in Switzerland, the United States and Czechia to under 50% in Iceland and Slovenia.
People with multiple chronic conditions often have more complex needs that may not be fully addressed in healthcare systems designed for single diseases, where time constraints and fragmented care models can limit the ability to provide comprehensive, person-centred care. PaRIS results highlight that scheduling more than 15 minutes for regular or follow-up consultations with primary care professionals and having a relationship of more than five years with the same care provider significantly improved the odds of experiencing better quality of care, by 21% and 30%, respectively. These results underline the importance of giving people with multimorbidity adequate time to address their concerns and ensure thorough care.
Conventional healthcare is primarily organised around single conditions, organ systems and specialties, with healthcare settings often siloed, and clinical guidelines focusing on single diseases while overlooking patient goals. Consequently, people living with multiple (two or more) chronic conditions often experience a lack of co‑ordination (Sherman, 2021[1]). They often visit multiple care professionals for different problems at multiple health and social care settings (Koch, Wakefield and Wakefield, 2014[2]), leaving them more vulnerable to receiving multiple, uncoordinated and potentially conflicting recommendations and care options. This can lead to low-quality, unsafe care. The growing patient population who live with multiple chronic conditions challenges the conventional strategies of patient care and pressures healthcare systems to adapt to continue providing high-quality safe care (Moody et al., 2022[3]).
Table 3.1 shows the state of health and well-being of people living with multiple chronic conditions on the selected key PROMs indicators (well-being, physical health, mental health and social functioning) (Box 3.1).
People with multiple chronic conditions have worse well-being with an average of 56 on the WHO‑5 Well-being Scale (degree to which a person feels positive in terms of their mood, vitality and fulfilment), ranging from 62 in the Netherlands and Switzerland to 48 in Wales (United Kingdom). In all participating countries, people with multiple chronic conditions reported less favourable physical health outcomes (ability to carry out every day physical activities, degree of pain and fatigue) with a cross-country range of 39‑46, with Portugal, Romania, Spain and Wales being below the good fair cut off point (42). In all countries, the mental health (perception of quality of life, mood and ability to think, satisfaction with social activities and relationships, emotional distress) of people with two or more chronic conditions was above the good-fair cut off point (40), with an OECD PaRIS average of 46. While most people living with multiple chronic conditions (80%) report good social functioning (extent to which a person can carry out their usual social activities and roles), the variation in social functioning is prominent (cross-country range of 65‑92). Variations across countries call for further assessment of health and quality of life in people with multiple chronic conditions and the factors influencing the outcomes and experiences of care.
This chapter presents how people living with multiple chronic conditions perceive their health outcomes, well-being and their experience of care in the PaRIS survey. First, the chapter shows how outcomes and experiences of care of people with two and three or more chronic conditions vary across countries and how these results compare to people with one chronic condition. Second, it also assesses how certain combinations of chronic conditions influence the health outcomes and healthcare experiences among people with multiple chronic conditions. Third, the chapter shows which features of primary care correlate with better outcomes and care experiences of people living with multiple chronic conditions and how the provision of primary care varies across countries. It concludes with policy and practice recommendations to enhance the quality of care for people with multiple chronic conditions.
Note: WHO‑5 well-being index. Response to five questions measuring well-being. Raw scale 0‑25 converted to 0‑100 scale with 0 being the lowest possible well-being and 100 the highest, and a good-fair cutoff of 50. PROMIS® Scale v1.2 – Global Health component for physical health is a T-score metric with a range of 16‑68, and a good-fair cutoff of 42, higher values represent better physical health. PROMIS® Scale v1.2 – Global Health component for mental health is a T-score metric with a range of 21‑68, and a good-fair cutoff of 40, higher values represent better mental health. PROMIS® Scale v1.2 – Global Health item on social functioning. Percentage of patients that responded good, very good or excellent (as compared to fair or poor) to the question: “In general, please rate how well you carry out your usual social activities and roles [further specified in questionnaire]”.
1. Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions.
2. United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
Multiple chronic conditions (multimorbidity) refers to the presence of two or more chronic conditions in an individual. The presence of chronic conditions among PaRIS respondents was measured through self-reporting. While we refer throughout the report to people with one, two, three or more chronic conditions, or people with multiple chronic conditions, the method may underestimate the prevalence of multimorbidity in cases where people have multiple conditions falling into the same category. To avoid overestimation in the number of chronic conditions for some respondents who may report higher than actual diagnoses, respondents were specifically asked to report conditions that they were “told by a doctor”.
Managing multiple chronic conditions is often more complex and resource‑intensive than managing a single condition, posing greater challenges for patients, healthcare professionals and healthcare systems alike. It typically requires frequent and longer medical appointments with multiple healthcare professionals, which significantly disrupt patients’ daily lives and work. This leads to greater societal costs, including productivity losses due to missed workdays. Healthcare systems face dual challenge of providing high-quality care for multimorbidity care while also shouldering the economic and societal burden it represents (Tran et al., 2022[4]).
“The main difficulty derives from the fact that I have to visit more than one doctor, doctors of different specialty. This costs me energy, money and time, because I have to change my work/daily routine.”
Zoe, 67 years old, divorced woman, living with severe osteoporosis, asthma and Paget disease
The economic burden on health systems of multimorbidity is considerable. In Switzerland average healthcare costs were approximately six times higher for older adults with multimorbidity than for those without any chronic conditions. In Ontario, Canada, people living with multiple chronic conditions accounted for 68% of total healthcare costs while only representing 24% of the population (Thavorn et al., 2017[5]). In the United States, annual Medicare payments for beneficiaries ranged from USD 7 172 for people with one chronic condition to USD 14 931 for people with two chronic conditions and USD 32 498 for people with three or more chronic conditions (Schneider, O’Donnell and Dean, 2009[6]). In the United Kingdom, people with multimorbidity were found to use healthcare services 2.56 times more than people with one or no chronic conditions, while the odds of unplanned, preventable hospitalisations go up to 14.38 times for people with four or more chronic conditions compared to those without any chronic condition (Soley-Bori et al., 2020[7]).
Multimorbidity impacts society at large, leading to increased emotional, physical, and financial burdens among people living with chronic conditions, their caregivers and families. Indirect costs, including productivity losses from sick days, rise as the number of chronic conditions increases. Multimorbidity can significantly reduce work productivity by increasing absenteeism rates (Fouad et al., 2017[8]). In a population study of US adults, having multiple chronic conditions increased the average missed workdays due to illness by 3‑9 days in a year (Ward, 2015[9]). In another study, the average missed workdays accounted for twice among those with four and more chronic conditions on 14.5 days compared to 7.4 days among those with two or three chronic conditions. In addition, certain disease combinations result in more missed workdays. For example, adults with arthritis/diabetes/heart disease and diabetes/heart disease missed more workdays compared to those with arthritis/hypertension (Meraya and Sambamoorthi, 2016[10]). Conversely, the combinations of diabetes/hypertension had lower missed workdays compared to arthritis/hypertension.
“Living with multiple chronic conditions profoundly impacts my overall well-being, mental health, work, and social life. Managing various health issues often leads to physical fatigue and emotional stress, which can be overwhelming. The constant need for medical appointments and medication management can disrupt my work routine and reduce my productivity. This uncertainty can also lead to anxiety about my health, making it difficult to focus and engage fully at work.”
Betsy, 68 years old, female, living with multiple chronic conditions, including obesity, dedicated caregiver for her husband, who is battling cancer, and for her daughter, who has Type 1 diabetes and chronic kidney disease
The high burden of multimorbidity on people, healthcare, economies and societies stress the need for ensuring good quality safe care for people living with multiple chronic conditions. If managed well and given the tools to self-manage, people with multiple chronic conditions can also be productive and contribute to healthier societies. Healthcare systems can enhance the physical health, mental health and social lives of those living with multiple chronic conditions, as well as their experiences with healthcare services. To do so, policy makers need information about health and quality of life of people with multiple chronic conditions and the characteristics of healthcare that influence the outcomes and experiences of those living with multiple chronic conditions.
“My life has been affected by numerous health problems and personal tragedies. After a difficult divorce and the trauma of my mother’s death (suicide), I discovered a tumour in my breast in 2010, which led to chemotherapy and surgery. A BRCA1 genetic mutation led me to a hysterectomy in 2012, which brought further complications, including thinning bones. In 2013, I had a preventative removal of my second breast. This was followed by thyroid problems and tongue cancer, which led to further surgery and radiation. In 2020, a recurrence of breast cancer occurred, followed by surgery and proton therapy. During this period, I also faced the death of my father, who committed suicide. I am now dealing with long-term physical effects such as mobility issues, pain and dry mouth, which require constant care and therapy.”
Nikola, 48 years old, female, has a history of breast and tongue cancer
Eight out of ten people (82%) aged 45 years and older using primary care services in the past six months report living with at least one chronic condition (Chapter 2) and 52% with two or more.
Most frequently reported chronic conditions were hypertension (53% with a cross-country range of 44‑66%), arthritis or ongoing problem with back or joints (36% with a cross-country range of 23‑60%), cardiovascular conditions (21% with a cross-country range of 15‑41%) and diabetes (21% with a cross-country variation of 12‑54%). On average, 15% of people with chronic conditions report having depression, anxiety or other mental health condition, varying from 8% to 31% across countries.
Among people living with chronic conditions, more than six out of ten (64%) reported having two chronic conditions or more (Figure 3.1). Around 35% reported having three or more chronic conditions, indicating that multimorbidity has become the norm rather than the exception in primary care, and underscoring the need for healthcare systems and healthcare professionals to be adequately equipped to manage patients with multiple chronic conditions.
Note: *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions.
**United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
A cumulation of chronic conditions goes hand in hand with a high number of medicines. People living with multiple chronic conditions typically are prescribed numerous medications and usually consult different healthcare professionals in various healthcare settings.
PaRIS results show that above 70% of people with multiple chronic conditions take at least three different medicines on a regular or ongoing base, and above 35% take four medicines or more. Taking multiple medications makes people vulnerable to unsafe care due to side effects, negative medicine interactions, and increases treatment burden and complexity of self-management (de Bienassis et al., 2022[11]).
“It is challenging to manage several conditions and being a carer of a disabled child as my anxiety can take a toll on all my health conditions. I take three medications for my heart, two for the allergy, and two for the acute pains.”
Lana, identifies herself as a person of colour, 45 years old, female, mother of two boys
3.3.1. People with multiple chronic conditions are at risk of worse quality of life
Living with multiple chronic conditions leads to worse health and well-being (Makovski et al., 2019[12]). PaRIS data show that patient-reported outcomes of people living with multiple chronic conditions differ from those who live with one chronic condition. This pattern underscores the compounded health burdens experienced by people with multiple chronic conditions, highlighting the escalating impact of each additional chronic condition on health and well-being.
Well-being decreases with an additional chronic condition
People with two or more chronic conditions report worse well-being than those with one condition (Figure 3.2). The WHO‑5 well-being scores show a significant decline as the number of chronic conditions increases. The psychological toll of multiple chronic conditions can lead to feelings of frustration, helplessness, and social isolation, further impacting overall well-being (Sand et al., 2021[13]).
Across PaRIS countries, the mean score on the WHO‑5 well-being score (a scale from 0 to 100) was five points lower among people with two chronic conditions and 14 points lower among people with three or more chronic conditions compared to people with one chronic condition. Between people with two chronic conditions and people with one chronic condition, the variation across countries was minor, ranging from seven points in Wales and Spain to three points in Saudi Arabia. However, the difference in average scores between people with one chronic condition and those with three or more chronic conditions was above 15 points in Spain, Romania, Portugal and Wales.
Note: WHO‑5 well-being index. Response to five questions measuring well-being. raw scale 0‑25 converted to 0‑100 scale, higher scores represent higher well-being. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Differences between one and two or more chronic conditions are statistically significant (p<0.05) for all countries except US population.
Source: OECD PaRIS 2024 Database.
In all countries people with multiple chronic conditions report worse physical health than people with one chronic condition
The decrease in physical health can be attributed to the compounded effects of multiple chronic conditions. Each additional condition introduces new symptoms, management requirements, and physical limitations, making it increasingly difficult for people to maintain their physical health. For example, a person with type II diabetes and severe arthritis may struggle with mobility issues and blood glucose management, leading to further physical decline and reduced overall functioning.
People with multiple chronic conditions report worse physical health compared to people living with one chronic condition (Figure 3.3). People with three or more chronic conditions are even less likely to report good physical health compared to those with two chronic conditions. The difference between people with one and two chronic conditions was about three to four, showing little variations across countries. In most countries except in Australia, Canada, Saudi Arabia, Switzerland and the United States, the physical health of people with three or more chronic conditions was below good-fair cutoff (42).
Note: PROMIS® Scale v1.2 – Global Health component for physical health is a T-score metric with a range of 16‑68, and a good-fair cutoff of 42, higher values represent better physical health. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Differences between one and three or more conditions are statistically significant (p<0.05) for all countries.
Source: OECD PaRIS 2024 Database.
People with multiple chronic conditions are more likely to report worse mental health
Mental health scores show a significant decline with an increasing number of chronic conditions. The lower scores in mental health might reflect the heightened stress, anxiety, and depression associated with having multiple chronic conditions. PaRIS results show that people with one chronic condition have better mental health compared to those with multiple conditions, with the lowest scores observed in those with three or more conditions in all countries (Figure 3.4). Nevertheless, in all countries but Portugal, the average mental health score of people with three and more conditions stayed above the good-fair cutoff point (40).
“I was diagnosed with uncontrollable hypertension at the age of 30, which is genetically influenced due to strong family history of diabetes, hypertension, asthma and arthritis. My current diagnoses are uncontrollable hypertension, pre‑diabetes, arthritis, chronic back aches (lived with acute pains for 13 years now), severe allergic rhinitis, and lived experience of mental health issues. I visit my GP every few months and must undergo blood tests and urine tests to check my liver and kidney function on an annual basis. I also suffer from myopia, but this is a very common diagnosis. My concern is my mental health, which affect the hypertension, because I am the primary carer of my son, who is diagnosed with autism spectrum disorder and intellectual disability. My phyco-social well-being is poor and as a result I do not work.”
Lana, identifies herself as a person of colour, 45 years old, female, mother of two boys
Note: PROMIS® Scale v1.2 – Global Health component for mental health is a T-score metric with a range of 21‑68, and a good-fair cutoff of 40, higher values represent better mental health. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Differences between one and three or more conditions are statistically significant (p<0.05) for all countries.
Source: OECD PaRIS 2024 Database.
Fewer people with multiple chronic conditions report good social functioning on average, and the gap between people with one and those with more conditions differs more than two‑fold across countries
PaRIS results reveal that people with multiple chronic conditions less often report good social functioning (Figure 3.5). This underscores the impact of multiple chronic conditions on an individual’s ability to engage in social roles and activities. This can be attributed to several factors associated with chronic conditions. Physical limitations and fatigue caused by multiple conditions can hinder participation in social activities. For example, a person with severe arthritis and diabetes might find it challenging to attend social gatherings due to pain and the need for frequent blood glucose monitoring.
“Having more than one chronic disease makes me feel insecure; there are many times when I am thinking of having a more active social life, but then I am thinking of the possible dangers I may face, and I postpone every plan. I feel that I am always thinking about my health, and that’s the biggest impact in my life. Also, since I am a 67 divorced woman, my greatest fear is that things will become even harder for me in the future.”
Zoe, 67 years old, divorced woman living with severe osteoporosis, asthma and Paget disease
On average, the difference between the percentage of people with two chronic conditions and one chronic condition who rated their social functioning as good, very good, or excellent was 5 percentage points. The difference among people with one and three or more chronic conditions was more than two‑fold ranging from 10% or less in France and Saudi Arabia to 20% and above in Australia, Spain, Norway, Iceland, Wales and Portugal.
Note: PROMIS® Scale v1.2 – Global Health. Answer to the question: “In general, please rate how well you carry out your usual social activities and roles [further specified in questionnaire]”, “good, very good or excellent” versus “fair or poor”. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Differences between people with one and three or more chronic conditions was statistically significant (p<0.05) in all countries.
Source: OECD PaRIS 2024 Database.
“I feel very vulnerable because I have Hashimoto, osteoporosis and hypertension. I think that these health problems impact my social life, and I always feel insecure that I will face a crisis of one of these health problems and that will make my daily life even more difficult.”
Lucy, 55 years old, divorced woman with osteoporosis, Hashimoto/thyroid, hypertension
Combinations of diseases are as important as the total number of chronic conditions. Certain combinations of chronic conditions lead to higher healthcare costs (Tran et al., 2022[4]), highlighting the need for targeted policy interventions. For instance, having a mental condition alongside cancer increases healthcare costs up to six times compared to other condition dyads (i.e. combination of two chronic conditions) such as hypertension and back pain. Some combinations are highly prevalent with any dyad involving hypertension cover more than half of the adult population (Tran et al., 2022[4]). Understanding the health and well-being trends in specific disease groups is crucial to ensuring high-quality care for people living with multiple chronic conditions.
The PaRIS data highlight the high prevalence of certain chronic conditions occurring together, particularly those involving hypertension, arthritis, cardiovascular disease, and mental health, underscoring the need for integrated care models to address these overlapping health concerns. Among people with chronic conditions, the most common combination is arthritis with hypertension, affecting 27% of the population. This pairing is particularly important to address as arthritis and other musculoskeletal problems might associate with worse physical functioning and well-being than other chronic conditions, thus less participation in social activities (Cheng et al., 2019[14]). This is followed by cardiovascular disease with hypertension at 20% and diabetes with hypertension, at 18%.
Percentage of most common combinations of chronic conditions among people with two or more conditions
Source: OECD PaRIS 2024 Database.
To explore variations in health and quality of life of people with different types of multiple chronic conditions, the conditions in this chapter are grouped into three categories concordant conditions, discordant conditions and mental health group (See Box 3.2 for definitions).
The combinations of chronic conditions in this chapter were analysed in three categories:
Concordant conditions include commonly occurring conditions that share similar genetic, behavioural, or environmental pathways. In PaRIS, this group includes two or more chronic conditions of high blood pressure, cardiovascular or heart condition, diabetes and chronic kidney disease, excluding other conditions (e.g. arthritis, mental health). For example, a patient with type II diabetes, chronic kidney disease and ischaemic heart disease would be in this group.
Discordant conditions include a varied assortment of individual conditions that are not explained by a common mechanism. In PaRIS, the discordant conditions group includes two or more chronic conditions, with at least one being one of the following: arthritis, breathing conditions, Alzheimer’s disease, neurological diseases, chronic liver disease and cancer, excluding mental health. This group includes any chronic conditions in the PaRIS survey except mental health conditions. For example, a patient with arthritis, chronic kidney disease, and type II diabetes, or a patient with arthritis and asthma, would fall into this group.
The mental health group includes two or more chronic conditions of which at least one being a mental health condition. The other chronic condition(s) can be any, including those from the concordant and discordant groups. For example, a patient with congestive heart failure, chronic kidney disease, and depression, or a patient with neurological disease, heart disease, and anxiety, would be classified in this group.
Measurement of chronic condition clusters in PaRIS
Chronic condition clusters in PaRIS were developed based on a rapid review of the literature, expert input, and the availability of condition categories in the PaRIS patient questionnaire. Some chronic conditions could belong to different clusters depending on their underlying causes. For instance, chronic kidney disease may result from type II diabetes or a congenital disorder. In the case of type II diabetes, the condition would fall into the “concordant” group, while a congenital cause would place it in the “discordant” group. However, the PaRIS had limitations in distinguishing these causes, and such nuances should be carefully considered when interpreting the results.
Source: Whitty, C. et al. (2020[15]), “Rising to the challenge of multimorbidity”, https://doi.org/10.1136/bmj.l6964; Stokes, J. et al. (2017[16]), “Does the impact of case management vary in different subgroups of multimorbidity? Secondary analysis of a quasi‑experiment”, https://doi.org/10.1186/s12913-017-2475-x; Tran, P. et al. (2022[4]), “Costs of multimorbidity: a systematic review and meta‑analyses”, https://doi.org/10.1186/s12916-022-02427-9.
The distribution of chronic condition clusters in PaRIS differs across countries. On average, 22% of people with multiple chronic conditions fall into the concordant group, 53% into the discordant group, and 24% into the mental health group. In all countries, the group with discordant conditions was the largest, making about half of the PaRIS population living with two or more chronic conditions. Discordant conditions were most prevalent in the US population of people aged 65 years and older (69%) and least prevalent in Portugal (45%). While Australia had the highest share of people with mental health conditions (40%), Italy had the highest share of concordant conditions (32%).
Percentage of people with multiple chronic conditions in each chronic condition cluster
1. Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions.
2. United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
3.4.1. Mental health matters: People with at least one mental health condition need social care and support
The results from PaRIS show that among people living with multiple chronic conditions, those with at least one mental health condition are more vulnerable than people who live without any mental health conditions. Figure 3.7 shows that people who report at least one mental health condition besides other conditions have worse physical health compared to people without mental health conditions, with an OECD average of 41 which is below the good-fair cutoff (42).
Note: PROMIS® Scale v1.2 – Global Health component for physical health is a T-score metric with a range of 16‑68, and a good-fair cutoff of 42, higher values represent better physical health. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Differences between groups are statistically significant (p<0.05) for all countries except for the Netherlands between discordant and mental health group.
Source: OECD PaRIS 2024 Database.
Fewer people reported good social functioning among the group with mental health conditions (OECD PaRIS average 64%) than among the other two groups (OECD PaRIS average respectively 91% for concordant conditions and 83% for discordant conditions). The gap between people with concordant or discordant conditions and mental health group varies more than two‑fold across countries (Figure 3.8), highlighting the social care needs of people with mental health conditions.
“As a patient with multiple chronic illnesses, I confirm that my health status strongly influences my mental health and social life. I was diagnosed ten years ago when I was going through a period of uncertainty and significant fatigue. That limited my mobility and made me dependent on the help of others. This situation negatively affected my mental health and completely shut down my social life. After the diagnosis and treatment, my health improved, allowing me to return to work and function partially. Although there were better days, the illness worsened at times and caused a significant deterioration in my mood. During these challenging periods, I sought psychological help to help me cope with the disease and its consequences.”
Olga, 68 years old, female, living with a rare disease – polymyositis, antisynthetase syndrome and interstitial lung disease
Note: PROMIS® Scale v1.2 – Global Health. Answer to the question: “In general, please rate how well you carry out your usual social activities and roles [further specified in questionnaire]”, “good, very good or excellent” versus “fair or poor”. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Differences between groups are statistically significant (p<0.05) for all countries except for Czechia, Greece, the Netherlands, Slovenia, Switzerland and the United States between concordant and discordant groups.
Source: OECD PaRIS 2024 Database.
Healthcare systems need to address this issue through integrated care models that provide co‑ordination with social care services and support people with mental health conditions. Such models should focus on enhancing care co‑ordination, improving access to social care services, and supporting self-management to mitigate the impact of multiple chronic conditions, and notably mental health conditions, on social lives. Additionally, primary care professionals should be equipped with the necessary resources and training to manage the complex needs of these patients effectively.
Primary care plays a crucial role in co‑ordinating care for people with multiple chronic conditions, making it a natural setting for implementing strategies and interventions like care co‑ordination. It also helps empowering patients to manage their own health more effectively.
Well-designed primary care systems offer significant advantages from a population health perspective, with a strong body of evidence supporting its positive impact on health outcomes (Hansen et al., 2015[17]). For instance, robust primary care systems have been linked to better health in people with chronic conditions such as ischemic heart disease, cerebrovascular disease, and other long-term conditions (Kringos et al., 2013[18]). Notably, strong primary care systems have also been associated with better health outcomes in people with multiple chronic conditions, who are more likely to report good or very good health if they reside in countries with well-structured primary care systems, characterised by high continuity of care and a broad range of services (Hansen et al., 2015[17]). In addition, there is strong evidence that primary care interventions can positively influence mental health outcomes, including improvements in depression and anxiety symptoms (Conejo-Cerón et al., 2017[19]).
The essential functions of primary care – serving as the first point of contact, providing person- and community-centred care, and delivering comprehensive, continuous, co‑ordinated services – are key factors that enable it to effectively manage chronic conditions over time (OECD, 2020[20]). Therefore, primary care’s unique position enables it to comprehensively understand a patient’s medical history and current needs, playing a pivotal role in co‑ordinating care for people with multiple chronic conditions. It also contributes to empowering patients to manage their own health more effectively through providing and co‑ordinating self-management support (Dineen-Griffin et al., 2019[21]).
The comprehensiveness of primary care is one of the most influential factors for improving health outcomes, particularly in addressing the complex needs of patients with multiple chronic conditions. People with multimorbidity tend to experience better health, fewer limitations in daily functioning, and reduced need for long-term treatment in countries where primary care offers a wider array of services (Smith et al., 2016[22]). Additionally, continuity of care in primary care settings is advantageous for managing conditions that are especially responsive to primary care interventions, highlighting the importance of the ongoing relationship between patients and primary care teams, the management and communication of health information, and the care co‑ordination (OECD, 2020[20]).
“I am thankful and grateful that I have a family GP for 13 plus years now. He is kind to me and understands the context to my health status. He hasn’t added pressure and stress to my health situation and supported me. I was given the option to attend a physiotherapist for back issues, a dietitian and mental health well-being help to manage anxiety. He has given me discounts and [universal health insurance scheme] funded sessions as well as placed me as a hypertension acute care programmes and healthcare plans. I also receive vaccinations and well-being management apps to keep on top of my mental and physical health. It was challenging as I had COVID‑19 three times and influenza twice with number of other viral infections. I believe my immune system is not up to date, due to all these infections, which makes it difficult to self-care and manage my chronic conditions. My GP will make urgent appointments, when I do not travel well.”
Lana, identifies herself as a person of colour, 45 years old, female, mother of two boys
3.5.1. Having self-management support in primary care is essential for the care of people with multiple chronic conditions
Having self-management support is crucial for people with multiple chronic conditions to manage their own health and care. People with multiple chronic conditions are frequent users of healthcare services. They are usually expected to co‑ordinate their own healthcare appointments, integrate recommendations from different healthcare professionals, manage medication use and navigate the healthcare system. The complexity of this can significantly strain patient capacity and resources (Verhoeff, 2023[23]). This can lead to missed appointments, inappropriate medication uses and difficulties with disease management as well as high treatment burden, experiences of fragmented care and uncertainty associated with lack of confidence in self-management for patients. Empowering patients with the knowledge and skills to manage their conditions effectively may improve managing their multiple chronic conditions and promote healthier lifestyles. Through self-management support, patients can develop self-efficacy and activation but also confidence and skills to manage their daily life and attain the best possible quality of life. This also helps to make the best use of all available resources by, for example, improving disease management, reducing hospitalisation and emergency visits, and improving health outcomes.
Fewer people are confident to manage their own health among those who have multiple chronic conditions
Fewer people with multiple chronic conditions are confident in their ability to manage their health and well-being compared to those with one chronic condition. Figure 3.9 shows that on average, the proportion of people who reported being confident or very confident was 10 percentage points lower among people with multiple chronic conditions compared to those with one condition. The gap was as high as over 13 percentage points in Czechia and Wales and below 5 percentage points in France. While in most countries more than half of people with multiple chronic conditions feel confident in self-managing their health, in a few countries (Wales, Romania, Norway, Greece, Iceland and Italy), less than half of people feel confident.
Note: P3CEQ Questionnaire. Response to question: “How confident are you that you can manage your own health and well-being?”, “confident or very confident” versus “somewhat confident or not confident at all”. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Differences between one and two or more chronic conditions are statistically significant (p<0.05) except for Australia, Belgium, Canada, Luxembourg, Portugal, and Slovenia.
Source: OECD PaRIS 2024 Database.
People with a mental health condition are less likely to be confident in managing their health compared to those without mental health conditions, who are in the concordant or discordant clusters.
Figure 3.10 illustrates that, on average, the proportion of people who feel confident or very confident in managing their health is almost 18 percentage points lower in the mental health cluster compared to the concordant group. In some countries, like Czechia and Slovenia, this gap is even larger, exceeding 30 percentage points. In some countries such as Romania, Greece, Iceland and Italy about only 30% of people with a mental health condition is confident to manage their health.
Note: P3CEQ Questionnaire. Response to question: “How confident are you that you can manage your own health and well-being?”, “confident or very confident” versus “somewhat confident or not confident at all”. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Differences are statistically significant (p<0.05) for Slovenia, Switzerland and Wales between the discordant and the mental health group and for Belgium, Czechia, France, Italy, Portugal, Romania, Saudi Arabia, Slovenia, Spain and Wales for between the concordant and the mental health groups.
Source: OECD PaRIS 2024 Database.
Primary care practices provide various options to support self-management
Patients managed in primary care practices that offer self-management support are more likely (14 percentage points) to report being confident that they can manage their own health (see Chapter 4).
Insights from PaRIS further highlight the readiness of primary care to offer self-management support. Based on the responses from primary care professionals, countries provide self-management support through multiple approaches. Most patients with multiple chronic conditions receive verbal information during or after the consultation (89%), which is provided by nurses in most countries, or self-management materials, such as booklets or web-based information (68%) (Table 3.3). However, the results indicate greater variability in other self-management support practices. For example, 39% of people with multiple chronic conditions are managed in practices where referrals to self-management classes or educators take place. About one‑third (35%) of patients are managed in practices where explicit goal setting and action planning with patients is offered. Moreover, only a quarter (25%) of patients visit primary care practices that have team members trained in patient empowerment and problem-solving, which may represent a gap in the availability of comprehensive support for patients managing chronic conditions.
PaRIS data show that when healthcare professionals provide written information, patients experience better care co‑ordination and person-centred care (Chapter 4). People with multiple chronic conditions often face complex consultations where the primary care professional usually address various issues such as issues in relation to different health conditions, medications, mental health and social lives. The amount of information provided in one session can sometimes be overwhelming for people with multiple chronic conditions, and patients might require written reminders or summaries after their visit (The HHS Interagency Workgroup on Multiple Chronic Conditions, 2011[24]).
Percentage of patients with two or more chronic conditions in primary care practices offering different self-management support types across countries; multiple responses were allowed
1. Data from a total of 49 243 patients with two or more chronic conditions linked to primary care practices in all PaRIS countries except for the United States, where the provider questionnaire was not applied.
Source: OECD PaRIS 2024 Database.
In 2011, the Slovenian Government invested in scaling-up of the management of people with chronic disease, particularly those with multiple chronic conditions, in primary care through “Renewed Family Medicine Practices”. A new member of a team, nurse practitioner, was added to the family medicine team in primary care practices. The nurse practitioner took on the preventive activities and managing patients with multiple chronic diseases. The registered nurses also perform individual consultations with patients regarding lifestyle and set goals to improve it.
In addition to standardising patients’ management, quality assurance and ensuring integrated, standardised, and person-centred approach; Renewed Family Medicine Practices enabled task share among primary care professionals in line with their competencies. It also included standardised protocols for diagnosis and treatment of diabetes and hypertension, health education, and guidelines on collaboration within the care team and between different providers e.g. health education centres in region, municipalities, clinical specialists on the secondary/tertiary care levels, social workers, and patient associations, which also provide health education and self-management support. The protocols consist of a clear description of the tasks that need to be done at primary care level for preventive activities and managing chronic patients.
A steering group of the Ministry of Health, consisting of professionals in the required fields, continuously monitor the established protocols and adapt them according to new evidence. This integrated way of managing patients is financed through the Health Insurance Institute of Slovenia. Evaluations of the programme showed the effectiveness of nurse‑led self-management programmes in improving self-management of chronic conditions.
Source: Klemenc-Ketis, Z. et al. (2021[25]), “Implementation of Integrated Primary Care for Patients with Diabetes and Hypertension: A Case from Slovenia”, https://doi.org/10.5334/ijic.5637; Klemenc‐Ketis, Z. et al. (2015[26]), “Role of nurse practitioners in reducing cardiovascular risk factors: a retrospective cohort study”, https://doi.org/10.1111/jocn.12889; Klemenc-Ketis, Z. et al. (2018[27]), “Transition from a traditional to a comprehensive quality assurance system in Slovenian family medicine practices”, https://doi.org/10.1093/intqhc/mzy157.
3.5.2. Appropriate care co‑ordination is essential in the care for multiple chronic conditions
Care co‑ordination is pivotal for improving outcomes and experiences of people living with multiple chronic conditions. This patient group has diverse and often conflicting needs of different conditions. In addition, they often need to navigate the healthcare system to visit multiple healthcare professionals in different healthcare settings. Primary care plays a decisive role in the co‑ordination of care for people living with multiple chronic conditions.
While co‑ordination of care may become more complicated when the number of conditions increases, people with multiple conditions are comparable to those with one chronic condition in how they experience care co‑ordination (Figure 3.11). The average score on experienced care co‑ordination varies from about 10 out of 15 points in Romania and Switzerland to below 6 points in Wales, with an OECD average of 8 points, which is relatively low.
Note: P3CEQ Questionnaire. Response to five questions measuring care co‑ordination. Scale ranges from 0 to 15, higher scores represent better care co‑ordination. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Results within countries between people with two or more chronic conditions and people with one chronic condition are statistically not significant (p<0.05).
Source: OECD PaRIS 2024 Database.
In a few countries such as Iceland, Italy, Portugal and Saudi Arabia, people with a mental health condition in addition to another chronic condition are more likely to report lower experienced care co‑ordination compared to those living with multiple chronic conditions without any mental health condition (Figure 3.12).
Note: P3CEQ Questionnaire. Response to five questions measuring care co‑ordination. Scale ranges from 0 to 15, higher scores represent better care co‑ordination. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Differences are only statistically significant (p<0.05) for Iceland, Italy, Portugal and Saudi Arabia between the concordant and the mental health groups.
Source: OECD PaRIS 2024 Database.
At the individual level, effective care co‑ordination strengthens the primary care safety net by fostering relationships with care providers, supporting patients, and facilitating the design and evaluation of both existing and innovative care models. These models are tailored to meet diverse health needs, settings, and life‑course perspectives, ultimately promoting health and well-being (Khatri et al., 2023[28]). However, the prevailing organisational model of primary care still predominantly relies on consultations with physicians operating in solo practices.
PaRIS results highlight the high importance of better care co‑ordination for people with multiple chronic conditions. In countries where patients report better quality of care, they also tend to report better experiences of care co‑ordination (Figure 3.13).
Note: P3CEQ Questionnaire. Response to five questions measuring care co‑ordination. Scale ranges from 0 to 15, higher scores represent better care co‑ordination. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Results are statistically significant (p<0.05) in all countries between people reporting very good or excellent, good and fair or poor experienced quality of care.
Source: OECD PaRIS 2024 Database.
Greater utilisation of teamwork, the involvement of other health professionals, and enhanced electronic communication could expand the capacity of each primary care physician to manage more patients, while simultaneously improving the quality of care provided (OECD, 2020[20]).
Most primary care practices do not have the necessary continuity of information to co‑ordinate care of people with multiple chronic conditions
Continuity of information is an integral component of care co‑ordination for people with multiple chronic conditions. Primary care practices in PaRIS reported the continuity of medical information throughout the patient pathway, and whether they can exchange patient clinical summaries or electronic medical records, which also contributes to enhanced care co‑ordination. On average, only 40% of people with multiple chronic conditions are managed in primary care practices where they receive medical records from previous practice without directly requesting them; 46% receives medical records if requested from the previous practice and 34% if patient brings them.
Percentage of people with two or more chronic conditions in primary care practices reporting the availability of medical records from previous practice; multiple responses were allowed
Note: Data from a total of 49 579 patients with two or more chronic conditions linked to primary care practices in all PaRIS countries except for the United States, where the provider questionnaire was not applied.
1. Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions.
Source: OECD PaRIS 2024 Database.
PaRIS data further show that in 14 out of the 19 countries 95% and more of the patients are managed in practices using electronic medical records (Chapter 4). However, only three countries (Belgium, the Netherlands and Norway) have more than 90% of patients managed in practices that are able to exchange medical records electronically with other primary care practices. The limited ability to exchange electronic information in the PaRIS data can reflect technological limitations (e.g. there are no systems in place for data sharing), regulatory limitation (e.g. regulations in place prevent data sharing), or lack of awareness of primary care practices about the data sharing capabilities (see Chapter 4 for further details).
Expanding care beyond physicians can enhance care co‑ordination in primary care
Having staff other than physicians to support patient education and chronic care management is not systematic in all countries (Table 3.5). On average, 72% of people with multiple chronic conditions are managed in primary care practices in PaRIS reporting additional staff for patient education and counselling (e.g. on tobacco use, diet or physical activity), ranging from 95% or more in Australia, the Netherlands, Slovenia, Portugal and Spain to below 40% in France, Luxembourg and Norway. Furthermore, additional staff managing certain tasks related to chronic disease management (e.g. diabetes control, wound care or measuring blood pressure) was available for 83% of patients with multiple chronic conditions, ranging from over 95% in Australia, Iceland, the Netherlands, Portugal, Slovenia, Spain and Wales, to 50% or less in France and Luxembourg. These two latter countries reported the highest percentages of patients receiving care in primary care practices that employ only physicians, 44% and 52%, respectively.
Percentage of people with two or more chronic conditions in primary care practices offering non-physician roles in chronic care support across countries
Note: Data from a total of 49 885 patients with two or more chronic conditions linked to primary care practices in all PaRIS countries except for the United States, where the provider questionnaire was not applied.
1. Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions.
Source: OECD PaRIS 2024 Database.
A typical Canadian publicly funded primary care practice in Quebec operates on a fee‑for-service model for family physicians, with global funding for other professionals provided by the Ministry of Health and Social Services. Family physicians work as independent practitioners in the clinics, while other healthcare professionals are salaried employees under the governance of a physician manager and often an administrative manager affiliated with the local health network of the practice’s service jurisdiction. Family physicians are responsible for initial diagnoses and treatments, and they collaborate closely with the clinic’s other team members, focusing on patients requiring more complex care. Older people are most frequent users of primary care practices, many with multiple chronic conditions. The clinics follow a shared-care model, where each healthcare professional plays a specific role in managing patients’ chronic conditions. Patients are registered under a family physician’s name but can see other professionals in the practice as needed for their condition.
Registered nurses play a pivotal role in collaboration with family physicians, especially in the management of people with multiple chronic conditions
Nurses manage people with multiple chronic conditions most of the time following a referral from the family physician or when the nurse independently identifies a follow-up need with patients they see in clinical practice (e.g. a walk-in patient needing diabetic care and anxiety management). Nurses often take the lead in creating personalised care plans for this patient group. They conduct initial and ongoing assessments, monitor vital signs, provide counselling, and help co‑ordinate care with other professionals. In Quebec, with the appropriate continued education and standing prescriptions, nurses can initiate medication for chronic conditions (e.g. hypertension, diabetes) once diagnosed and ensure follow-up and dosage adjustments. Nurses work closely with pharmacists, where available, when the patient’s medication regimen requires attention. Pharmacists help prevent complications related to polypharmacy, which is common in patients with multiple chronic conditions. Nurses may also refer patients to social workers, especially in cases of common mental health issues in primary care (such as anxiety and depression) or when chronic disease management presents adaptation challenges. Social workers provide psychological and social support, facilitate access to community resources (like food assistance or transportation services), and help reduce social isolation, which can impact treatment management and chronic disease management.
The clinic holds monthly team meetings where the staff discuss service organisation within the clinic and collaborative work methods, both intra- and interdisciplinary. Primary care professionals discuss the joint management of new health conditions or professional practice standards in these meetings. The interprofessional team also has informal exchanges in the clinic regarding patients they co-manage to align their respective approaches. While complex case discussions in team meetings add significant value, these “hallway” interdisciplinary discussions are more typical in primary care to ensure continuity and optimise clinical time dedicated to patients.
Shared electronic medical record, allowing each team member to access the latest patient information, support collective and consistent decision-making
The electronic medical records (EMR) are essential for the clinics’ continuous improvement. The physician managers, along with administrative staff, regularly extract aggregated data from EMR to identify patients with chronic conditions who visit frequently, miss appointments, or could benefit from interdisciplinary follow-up.
Source: Canadian National Project Managers.
3.5.3. Interventions such as medication reviews matter
Regular medication review is recognised as a key priority to optimise therapy and prevent medication-related harm. Medication reviews, undertaken by healthcare professionals and patients, are also important for shared decision-making, incorporating the needs and preferences of patients. Inappropriate polypharmacy is associated with prescription errors, problems with disease management and drug interactions, which represents a major avoidable economic and societal cost (Fitzpatrick and Gallagher, 2023[29]). Taking the example of patients with high blood pressure and cardiovascular conditions, if care is not adequately co‑ordinated and regular medication reviews are not conducted, patients may be prescribed antihypertensive medications by multiple healthcare providers, such as their family doctor, cardiologist, internist, and neurologist. This may occur because different healthcare professionals, working in various settings, may prescribe treatments for the same condition, particularly in patients with multiple chronic conditions.
As many as 1 in 10 hospitalisations in OECD countries may be caused by a medication-related event (de Bienassis et al., 2022[11]). A 2022 survey of OECD countries found that less than half of surveyed countries had implemented policies to support medication reconciliation at times of transitions in care (de Bienassis et al., 2022[11]). Primary care professionals are well-positioned to review medicines for people living with multiple chronic conditions, thus reduce the number of medicines taken by the patient and improve patient outcomes and experiences (Box 3.5).
Pilar is a family doctor in Spain, responsible for the care of 1 759 patients, with a significant percentage (47%) of them living with multiple chronic conditions.
Pilar collaborates closely with other specialists to ensure comprehensive care for her patients with chronic conditions. She regularly conducts thorough medication reviews, assessing not only her own prescriptions but also those issued by other specialists. This process allows her to evaluate if the medications are effectively supporting the patient’s health issues and well-being while monitoring for any potential risks.
When a patient reports symptoms or side effects related to medications, Pilar adjusts their medications as needed. She may also arrange a virtual consultation with the relevant specialist to discuss any necessary medication changes. Following these exchanges, Pilar meets with the patient to review the updated treatment plan, avoiding the need for the patient to visit another healthcare setting and making the conciliation of the multiple medications for a better patient experience.
Source: Pilar, family doctor.
More than 70% of people with multiple chronic conditions take at least three different medicines on a regular or ongoing base, and above 35% take four medicines or more. These results stress the importance of systematic medication reviews in the countries.
On average, about 70% of people living with multiple chronic conditions reported having their medication reviewed by a healthcare professional in the last six months (Figure 3.14). While about 90% of people with three of more chronic conditions have medication reviews in Czechia, Switzerland and Australia, the share is lower than 50% in Iceland and Slovenia.
In most countries, there is no difference in the percentage of people having a medication review between people with multiple chronic conditions and those with one condition. In some countries such as Luxembourg, Romania and Slovenia, more people with multiple chronic conditions have medication reviews compared to people with one chronic condition.
Percentage of people with one, two and three or more chronic conditions who reported their medication being reviewed over the past 12 months
Note: *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Differences between one and two or more chronic conditions are statistically significant (p<0.05) for Luxembourg, Romania and Slovenia. Differences between one and three or more chronic conditions are statistically significant (p<0.05) for Greece, Luxembourg, Romania, Saudi Arabia, Slovenia, Spain and Switzerland.
Source: OECD PaRIS 2024 Database.
PaRIS results highlight that people often experience better care co‑ordination when they have a medication review by a healthcare professional (Chapter 4). This relationship is even more prominent among people with three or more chronic conditions (Figure 3.15).
Percentage of people reporting having their medication reviewed and average score on experienced care co‑ordination
Note: P3CEQ. Response to five questions measuring care co‑ordination. Scale ranges from 0 to 15, higher values represent better experienced co‑ordination. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
3.5.4. Spending more time with primary care professionals is associated with better experiences of quality of care
People with multiple chronic conditions often have more complex needs, which might not be covered in health systems designed for single diseases with limited consultation time. The time spent on consultations, meeting the same primary care professionals, follow-up and relationship are perceived more important among people with multiple chronic conditions than patients with no chronic conditions (Norman, Jelin and Bjertnaes, 2024[30]).
PaRIS data show that people who live with multiple chronic conditions and have longer time with primary care professionals are more likely to report a good quality of care. The results show that having a long-standing relationship with primary care professional (longer than five years) was associated with an increase of 30% in the odds of experiencing quality of care (p < 0.001) (Box 3.6). Patients benefit from the trust, rapport, and understanding developed over time.
In addition, more time scheduled for regular or follow up consultations (more than 15 minutes) significantly improve the odds of experiencing good quality of care by 21% (p < 0.005) among people with multiple chronic conditions, underlining the importance of giving patients adequate time to address their concerns and ensure thorough care. Other factors, such as a higher number of chronic conditions, were associated with a decrease in the odds of experiencing good quality of care, reinforcing the need for tailored interventions for patients with complex health needs.
Estimated effects and 95% confidence intervals on overall quality of care, expressed in percentages
Note: Analysis includes 30 964 patients in 18 countries, only those with at least two chronic conditions were included. The United States was not included for not having information at the practice level for provision. Values shown are odds ratios, calculated by exponentiating the regression coefficients (𝑒Estimate) from the logistic regression model. These odds ratios represent the multiplicative change in the odds of the outcome for a one‑unit increase in the predictor variable, with bars extending to the right signifying increased odds and bars extending to the left indicating decreased odds, For the variable “Number of chronic conditions”, the effect reflects the marginal change, meaning the increase (or decrease) in the odds associated with having one additional chronic condition. Statistical significance: *** p < 0.001; ** p < 0.01; * p < 0.05. Male compared to female, Age groups compared to people from 45 to 54 years old; Education high and middle compared to people with low education. Random intercept models with patient, practice and country level.
Source: OECD PaRIS 2024 Database.
“Between birth and age 60 I had four GPs – for 30, 5, 10 and 15 years respectively. Since then, I have seen upwards of 20 different GPs. Without full and accurate exchange of records this can mean that much time is taken with familiarisation, and errors can occur. In the past, because I had a personal relationship with the GP this was rare, but recently less so. Similarly, the archaic way of referral to specialists, a legacy of the medical hierarchy is less than helpful.”
Anonymous person living with multiple chronic conditions
Experienced care quality was analysed to evaluate patient experiences, focusing on overall experienced quality of care. Using multilevel models with random intercepts, the analysis examined the associations between time spent per consultation and the duration of the patient-provider relationship. The models were adjusted for gender, age categories, level of education, number of chronic conditions, and unobserved variations at both the country and provider levels.
Experienced quality of care is based on the question: “When taking all things into consideration in relation to the care you have received, overall, how do you rate the medical care that you have received in the past 12 months from your primary care centre?”. Responses are rated on a scale of 1‑5, with the proportion of patients responding “good,” “very good,” or “excellent” compared to those responding “fair,” “poor,” or “not sure.”
Yijk = β0 + β1 (Consultation > 15 minijk) + β2 (Relationship > 5 yearsijk) + β3 (Number of chronic conditionsijk) + β4 (Maleijk) + β5 (Age 75 plusijk) + β6 (Age 65 to 74ijk)+ β7 (Age 55 to 64ijk) +β8 (High educationijk) + β9 (Middle educationijk) + uj + vjk + ϵ
Having a long-standing relationship (more than five years) was associated with an increase of 30% in the odds of experiencing good quality of care (p < 0.001). Time scheduled per regular or follow up consultation (more than 15 minutes) improved the odds of experiencing good quality of care by 21% (p = 0.0 049). Other factors, such as a higher number of chronic conditions, were associated with low probability of experiencing better quality of care.
Source: OECD PaRIS 2024 Database.
On average, less than half (47%) of patients with multiple chronic conditions are seen in primary care practices which schedule more than 15 minutes on regular and follow-up consultations, ranging from more than 80% in Norway and Portugal to less than 10% in Wales and Spain (Figure 3.17).
Percentage of people with multiple chronic conditions in participating primary care practices reporting time scheduled for regular or follow up consultation
Note: *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. Data from a total of 56 912 patients with two or more chronic conditions linked to primary care practices in all PaRIS countries except for the United States, where the provider questionnaire was not applied.
Source: OECD PaRIS 2024 Database.
On average, 58% of people with multiple chronic conditions have a relationship of more than five years with their primary care professional, achieving long-term continuity of care (cross-country range: 40‑74) (Figure 3.18). Nevertheless, among people who report a relationship of more than five years, 39% have been with their primary care professional for over 10 years. The highest proportions of patients with such long-term continuity were observed in Romania, Czechia and the Netherlands, where over 50% of patients reported 10 years or more.
Registration with a family doctor in the Czechia is a voluntary administrative act, which at the same time allows the patient to continuously benefit from care mediated exclusively by a family doctor, including, in addition to routine care, also prevention and screening, and especially co‑ordination of care provided by specialists and management of chronic conditions.
Less than 0.5% of people change their family doctor after the statutory 3‑month interval. 90% of people in the system are permanently registered and seek care through family doctors, even if strict gatekeeping is not established in the country.
Act on Public Health Insurance and on Amendments and Additions to Certain Related Acts
“Patient registration is an administrative act, which according to Act no. 48/1997, par. 11 Coll. (Act on Public Health Insurance and on Amendments and Additions to Certain Related Acts) must always follow after the doctor of the registering provider accepts the patient under his regular care. The registering provider in Czech ambulatory care is a general practitioner, a general practitioner for children and adolescents, a dentist (stomatologist) and also a gynaecologist.
The patient has the right to choose a registering ambulatory physician in the above‑mentioned primary care specialties and can change him again no earlier than 3 months after the previous registration.
Major part of the payment to the registering physician is made up of the so-called capitation, which is derived from the number of registered patients. Capitation payment varies according to age indices, which take into account the patient’s cost intensity.”
About half of people with multiple chronic conditions in Italy, Portugal, Spain, Saudi Arabia and Greece have relationships lasting five years or less. More than 20% of people with multiple chronic conditions in Spain, Portugal or Saudi Arabia report a relationship of less than a year.
Percentage of people with multiple chronic conditions reporting the length of time with the same primary care professional
Note: *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
Healthcare systems can redesign their services to enhance care for their population living with multiple chronic conditions. Essential elements of a healthcare system which offer high quality chronic care management are delivery system design, clinical information systems, decision support and self-management support (Wagner et al., 2005[31]). Strong primary care systems can assure effective, efficient care and self-management support (OECD, 2020[20]). Primary care professionals can promote care for people living with chronic conditions by considering scientific evidence and patient preferences. Health systems need to invest in and strengthen primary care to ensure that primary care practices and professionals are equipped to serve to the needs of their populations.
Co-designing and implementing integrated multimorbidity care programmes
To ensure healthcare systems deliver meaningful outcomes for people with multiple chronic conditions, the active inclusion of people with lived experience in decision-making processes is essential. Traditional healthcare structures, often organised around individual diseases or organ systems, fail to address the complex realities of multimorbidity. The growing prevalence of this multimorbidity necessitates a shift toward a people‑centred approach, emphasising integrated care over disease‑specific silos. Co-designing programmes tailored to the unique needs of people living with multimorbidity is critical, as this patient group is large and expanding rapidly, particularly in primary care settings (van der Heide et al., 2018[32]). To support this transformation, healthcare systems must invest in cross-cutting research, adaptable infrastructures, and funding mechanisms that extend benefits across multiple disease areas, fostering a more integrated and effective approach to care.
Reinforcing care co‑ordination for people with multiple chronic conditions through continuity
Effective care co‑ordination is essential for managing multiple chronic conditions. It is essential that primary care professionals co‑ordinate care closely with other specialists, mental health care professionals, and social care services to ensure that patients receive seamless, integrated, and “trouble‑free” care. Achieving this requires information continuity, supported by the exchange of health information and medical record sharing. Beyond the care co‑ordination role traditionally held by family doctors, introducing dedicated care co‑ordinators or other non-physician staff within primary care settings can enhance the management of care. These co‑ordinators can oversee appointments, prevent duplications, organise blood tests and other diagnostics, and ensure that treatment plans are consistent across providers. Such measures not only improve patient outcomes but also reduce inefficiencies across the healthcare system (Khatri et al., 2023[28]).
Improving medication reviews for patient safety and efficacy
Regular medication reviews can improve outcomes and experiences of people with multiple chronic conditions by preventing inappropriate polypharmacy and adverse drug interactions (McCahon et al., 2022[33]). Primary care professionals have a unique position to review medication plans, however they need to be equipped to assess and adjust medication plans as needed, in collaboration with patients and pharmacists, to optimise medication safety and efficacy, particularly for patients who take multiple medications.
PaRIS stresses that access to mental health care and its integration into primary care need to be more systematic to enhance the care of people with multiple chronic conditions. Addressing the mental health needs of people with multiple chronic conditions requires comprehensive mental health services integrated into chronic care management (Bierman et al., 2021[34]). Healthcare professionals should be equipped to recognise and address mental health issues, offering (referral to) counselling, therapy, and support groups as part of routine care. This integration ensures that mental health care is a core component of chronic care management.
Physical and mental health are profoundly interconnected, making a clear distinction between the two challenging. While PaRIS collects data on both physical functioning and psychological well-being, it’s crucial to understand that mental health conditions are also physical. This is because mental health conditions might involve physical changes in the brain and body, affecting various bodily functions. Therefore, the separation often made between these two aspects of health can be misleading, and an approach to health that considers the interplay of physical and mental well-being is essential for effective healthcare for people with multiple chronic conditions.
Policies should go beyond traditional healthcare and reinforce social support to people with multiple chronic conditions. Social support systems play a crucial role in enhancing well-being among people with multiple chronic conditions. Family, friends, community, and patient organisations can provide emotional and practical assistance, helping to alleviate some of the burdens associated with chronic conditions. Social prescribing and lifestyle medicine initiatives in primary care, which connect patients with community resources and activities, can also enhance well-being by promoting social interaction and reducing isolation. Investing in social care, particularly for people with multiple chronic conditions, is essential to ensure better social lives for this growing population.
People with multiple chronic conditions face a higher risk of diminished well-being, poorer health outcomes and worse healthcare experiences. Health policies need to shift from single‑disease approach to people‑centred care and address the needs of people living with multiple chronic conditions. Healthcare systems with strong primary care have the possibility to enhance the care of people with multiple chronic conditions by providing co‑ordinated care, self-management support and person-centred care. Relying solely on the results of randomised controlled trials, which often exclude people with multiple chronic conditions is unlikely to yield valuable insights for policy makers. To effectively address these needs healthcare systems must embrace a broader evidence base that incorporates the perspectives of those with lived experiences. Co-developing healthcare solutions with people living with multiple chronic conditions is essential to ensure that these transformations are appropriate, acceptable, and successful.
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