PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

56 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceItaly’s 2022 National Report on Medicine Use documents that 68.1% of citizens aged 65 and over received prescriptions for at least five different substances, meeting the definition of polypharmacy. More concerning, 28.6% take ten or more different active ingredients, representing extreme polypharmacy associated with increased risks of adverse drug interactions, reduced adherence, and iatrogenic harm (Italian Medicines Agency, 2023). Japan explicitly identifies this challenge, noting that simply combining treatment guidelines for each condition can lead to excessive treatment that potentially harms rather than helps patients. The need for personalised medical care that considers overall treatment burden and prioritises interventions based on patient goals rather than disease- specific targets becomes essential. Comprehensive guidelines for multimorbidity management remain notably absent across all studied countries. This gap means clinicians must navigate complex clinical decisions without evidence- based frameworks, often defaulting to treating each condition in isolation despite known interactions. The absence of multimorbidity guidelines particularly affects primary care providers, who provide generalist care to patients with MTLCs but lack support and specific recommendations for integrated decision-making. Care coordination and disease management programmes Effective NCD management requires sustained coordination across multiple providers, settings, and time periods. However, system fragmentation represents perhaps the most significant barrier to achieving this coordination, undermining the potential benefits of even excellent screening and diagnostic services that patients have successfully accessed. The persistence of fragmentation The persistence of poor outcomes despite substantial healthcare investments demonstrates that resource density alone does not guarantee effective chronic disease management. Germany, with very high density of physicians, medical technologies and infrastructure, reports avoidable hospitalisation rates for diabetes, COPD, heart failure, and hypertension that exceed OECD averages. More specifically, Germany recorded 363 congestive heart failure admissions per 100,000 population in 2021, 172 admissions for diabetes, and 193 for COPD/asthma – all higher than OECD averages (Figure 15). These indicators suggest that simply having abundant healthcare resources is insufficient without systematic approaches to organising and coordinating chronic disease care, and may also reflect incentives to maximise utilisation of existing infrastructure. The absence of shared electronic health records across multiple countries has created information silos even within individual institutions, limiting development of holistic, patient-centred approaches. This technological gap prevents care teams from accessing complete patient information, leading to duplicated tests, medication conflicts, and missed opportunities for coordinated intervention. Italy’s recent DM77 reform responds to this by promoting telemedicine as a tool for improving access to chronic care management, establishing community health centres as single access points where multidisciplinary teams provide integrated care. However, this framework is still in the early stages of implementation, and it will be some years before its full impact is realised.