References
- WHF Roadmaps:
https://world-heart-federation.org/cvd-roadmaps/whf-global-roadmaps/ - The NIHR Strategic Framework for Multiple Long-term Conditions Research; 2020. Accessed 23 January 2026.
https://www.nihr.ac.uk/nihr-strategic-framework-multiple-long-term-conditions?utm_source=chatgpt.com%20”NIHR%20Strategic%20Framework%20for%20Multiple%20Long-Term%20Conditions - Khunti K, Sathanapally H, Mountain P. Multiple long-term conditions, multimorbidity, and co-morbidities: we should reconsider the terminology we use. October 2023. BMJ. 2023;383:
2327 . DOI: 10.1136/bmj.p2327 - Khunti K, Chudasama Y, Gregg E, et al. Diabetes and Multiple Long-term Conditions: A Review of Our Current Global Health Challenge. Diabetes Care. 1 December 2023;46(12):2092–2101. DOI: 10.2337/dci23-0035
- Holland E, Matthews K, Macdonald S, et al. The impact of living with multiple long-term conditions (multimorbidity) on everyday life- a qualitative evidence synthesis. BMC Public Health. 2024 Dec 18;24(1):
3446 .https://pmc.ncbi.nlm.nih.gov/articles/PMC11654051/ ; DOI: 10.1186/s12889-024-20763-8 - Global, Regional, and National Burden of Cardiovascular Diseases and Risk Factors in 204 Countries and Territories, 1990–2023. JACC. 2025 Dec;86(22):2167–2243. DOI: 10.1016/j.jacc.2025.08.015
- Ndumele C, Rangaswami J, Chow S, et al. Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association. Circulation. 2023 Nov 14;148(20):1606–1635. DOI: 10.1161/CIR.0000000000001184
- Zhao D, Wang Y, Wong N, et al. Impact of Aging on Cardiovascular Diseases: From Chronological Observation to Biological Insights. JACC Asia. 2024 Apr 8;4(5):345–358. DOI: 10.1016/j.jacasi.2024.02.002
- Skou S, Mair F, Fortin M, Miranda J, et al. Multimorbidity. Nat Rev Dis Primers. 2022 Jul 14;8(1):
48 . PMID: 35835758; PMCID: PMC7613517.https://pubmed.ncbi.nlm.nih.gov/35835758/ ; DOI: 10.1038/s41572-022-00376-4 - Chowdhury S, Das D, Sunna T, et al. Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis. eClinicalMedicine. 57:
101860 .https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00037-8/fulltext - Lopez-Jimenez F, Di Cesare M, Powis J, et al. World Heart Report 2025: Obesity and Cardiovascular Disease.
https://world-heart-federation.org/report2025/ . Accessed 23 January 2026. - Neeland IJ, Ross R, Després JP, et al. Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: a position statement. Lancet Diabetes Endocrinol. 2019 Sep;7(9):715–725. Epub 2019 Jul 10. PMID: 31301983. DOI: 10.1016/S2213-8587(19)30084-1
- Nishiga M, Wang DW, Han Y, et al. COVID-19 and cardiovascular disease: from basic mechanisms to clinical perspectives. Nat Rev Cardiol. 2020;17:543–558. DOI: 10.1038/s41569-020-0413-9
- Tsampasian V, Bäck M, Bernardi M, et al. Cardiovascular disease as part of Long COVID: a systematic review, European Journal of Preventive Cardiology. April 2025;32(6):485–498. DOI: 10.1093/eurjpc/zwae070
- Echeverría LE, Marcus R, Novick G, et al. WHF IASC Roadmap on Chagas Disease. Global Heart. 2020;15(1):
26 .https://world-heart-federation.org/cvd-roadmaps/whf-global-roadmaps/chagas-disease/ ; DOI: 10.5334/gh.484 - Guochen L, Yu Y, Lin C, et al. Association between major depressive disorder or depressive symptoms and the risk of vascular complications among patients with type 2 diabetes, and the mediating role of metabolic biomarkers: an analysis of the UK Biobank cohort. eClinicalMedicine. 79:
102982 .https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(24)00561-3/fulltext - Polcwiartek C, O’Gallagher K, Friedman D, et al. Severe mental illness: cardiovascular risk assessment and management. European Heart Journal. 2024 March 21;45(12):987–997.
https://academic.oup.com/eurheartj/article/45/12/987/7611764 ; DOI: 10.1093/eurheartj/ehae054 - Kwapong Y, Boakye E, Khan S, et al. Association of Depression and Poor Mental Health With Cardiovascular Disease and Suboptimal Cardiovascular Health Among Young Adults in the United States. Journal of the American Heart Association. 12(3). DOI: 10.1161/JAHA.122.028332
- Hill-Briggs F, Adler NE, Berkowitz SA, et al. Social Determinants of Health and Diabetes: A Scientific Review. Diabetes Care. 2020 Nov 2;44(1):258–79. Epub ahead of print. PMID: 33139407; PMCID: PMC7783927. DOI: 10.2337/dci20-0053
- Chong B, Jayabaskaran J, Jauhari S, et al. The Global Syndemic of Modifiable Cardiovascular Risk Factors Projected From 2025 to 2050. JACC. 2025 Jul;86(3):165–177. DOI: 10.1016/j.jacc.2025.04.061
- Han S, Li S, Yang Y, Liu L, Ma L, Leng Z, Mair FS, Butler CR, Nunes BP, Miranda JJ, Yang W, Shao R, Wang C. Mapping multimorbidity progression among 190 diseases. Commun Med (Lond). 2024 Jul 11;4(1):
139 . PMID: 38992158; PMCID: PMC11239867. DOI: 10.1038/s43856-024-00563-2 - Jeemon P, et al. World Heart Federation Roadmap for Hypertension – A 2021 Update. Global Heart. 2021;16(1):
63 . DOI: 10.5334/gh.1066 - WHF. A Roadmap on the Prevention of Cardiovascular Disease Among People Living With Diabetes. GLOBAL HEART. 2019 September;14(3):215–240. DOI: 10.1016/j.gheart.2019.07.009
- Zhou B, et al. Worldwide trends in diabetes prevalence and treatment from 1990 to 2022: a pooled analysis of 1108 population-representative studies with 141 million participants. Lancet 2024;404: 2077–93. Published Online November 13, 2024
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02317-1/fulltext - WHO Factsheet on Noncommunicable Diseases:
https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases . Accessed 23 January 2026. - NCD Alliance. The Global Epidemic:
https://ncdalliance.org/the-global-epidemic#:~:text=NCDs%20make%20the%20largest%20contribution,and%20an%20urgent%20development%20issue . Accessed 23 January 2026. - WHO Study on global AGEing and adult health (SAGE):
https://www.who.int/data/data-collection-tools/study-on-global-ageing-and-adult-health . Accessed 21 January 2026. - Bazo-Alvarez JC, Del Castillo D, Piza L, et al. Multimorbidity patterns, sociodemographic characteristics, and mortality: Data science insights from low-resource settings. Am J Epidemiol. 2024 Dec 19;kwae466. Epub ahead of print. PMID: 39703173. DOI: 10.1093/aje/kwae466
- Sbolli M, Fiuzat M, Cani D, O’Connor CM. Depression and heart failure: the lonely comorbidity. Eur J Heart Fail. 2020 Nov;22(11):2007–2017. Epub 2020 May 29. PMID: 32468714.
https://pubmed.ncbi.nlm.nih.gov/32468714/ - Schmaderer M, Struwe L, Pozehl B, et al. Health Status and Burden in Caregivers of Patients With Multimorbidity. Gerontology and Geriatric Medicine. 2020;
6 .https://journals.sagepub.com/doi/full/10.1177/2333721420959228 - Tsang JY, Sperrin M, Blakeman T, et al. Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. BMJ Open. 2024;14:
e081698 .https://bmjopen.bmj.com/content/14/5/e081698 - Anza-Ramirez C, Najarro L, Bernabé-Ortiz A, Diez-Canseco F, Fottrell E, Abubakar I, Hernández-Vásquez A, Carrillo-Larco RM, Hurst JR, Miranda JJ. Multimorbidity and acute infectious diseases in urban and semi-urban settings in Peru: A mixed-methods study. J Multimorb Comorb. 2024 May 23;14:
26335565241256826 . PMID: 38798989; PMCID: PMC11119522. DOI: 10.1177/26335565241256826 - Li Z, Shi J, Li N, et al. Temporal trends in the burden of non-communicable diseases in countries with the highest malaria burden, 1990–2019: Evaluating the double burden of non-communicable and communicable diseases in epidemiological transition. Global Health. 2022;18:
90 . DOI: 10.1186/s12992-022-00882-w - Basto-Abreu A, Barrientos-Gutierrez T, Wade A, et al. Multimorbidity matters in low and middle-income countries. Journal of Multimorbidity and Comorbidity. 2022;12:
263355652211060 .https://www.researchgate.net/publication/361367539_Multimorbidity_matters_in_low_and_middle-income_countries - Bygbjert IC. Double Burden of Noncommunicable and Infectious Diseases in Developing Countries. Science. 21 Sep 2012;337(6101):1499–1501. DOI: 10.1126/science.1223466
- Mocumbi A. Cardiovascular Health Care in Low- and Middle-Income Countries. Circulation. 149(8). DOI: 10.1161/CIRCULATIONAHA.123.065717
- Tran PB, Kazibwe J, Nikolaidis GF, et al. Costs of multimorbidity: a systematic review and meta-analyses. BMC Med. 2022;20:
234 . DOI: 10.1186/s12916-022-02427-9 - Prior A, Vestergaard CH, Vedsted P, et al. Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study. BMC Med. 2023;21:
305 . DOI: 10.1186/s12916-023-03021-3 - Gaspar A, Miranda JJ. Burden of treatment as a measure of healthcare quality: An innovative approach to addressing global inequities in multimorbidity. PLOS Glob Public Health. 2022 May 10;2(5):
e0000484 . PMID: 36962213; PMCID: PMC10021660. DOI: 10.1371/journal.pgph.0000484 - Nieuwlaat R, Schwalm JD, Kahtib R, Yusuf S, et al. Why are we failing to implement effective therapies in cardiovascular disease? European Heart Journal. 1 May 2013;34(17):1262–1269. DOI: 10.1093/eurheartj/ehs481
- Boehmer KR, Gallacher KI, Lippiett KA, et al. Minimally Disruptive Medicine: Progress 10 Years Later. Mayo Clin Proc. 2022 Feb;97(2):210–220. PMID: 35120690. DOI: 10.1016/j.mayocp.2021.09.003
- Kruk ME, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health. 6(11):e1196–e1252. DOI: 10.1016/S2214-109X(18)30386-3
- Ski C, Cartledge S, Foldager D, et al. Integrated care in cardiovascular disease: a statement of the Association of Cardiovascular Nursing and Allied Professions of the European Society of Cardiology. European Journal of Cardiovascular Nursing. July 2023;22(5):e39–e46.
https://academic.oup.com/eurjcn/article/22/5/e39/6973027 - Amelung V, et al.
Handbook Integrated Care ; 2021. Springer Nature.https://link.springer.com/book/10.1007/978-3-030-69262-9: https://www.sciencedirect.com/science/article/pii/S0168851017301665?via%3Dihub - OECD. People-centred health systems and integrated care:
https://www.oecd.org/en/topics/people-centred-health-systems-and-integrated-care.html . Accessed 23 January 2026. - Barnett K, Mercer S, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet, 2012;380(9836):37–43.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60240-2/fulltext - WHO Regional Office for Europe. Primary health care on the road to universal health coverage: 2019 monitoring report; 2019.
https://www.who.int/publications/i/item/9789240029040 - WHO Primary Healthcare: Making our Commitments Happen:
https://www.who.int/europe/health-topics/primary-health-care#tab=tab_1 - OECD. Health system resilience:
https://www.oecd.org/en/topics/health-system-resilience.html - Coyle M, Davis M, Langley M. Integrated Care during the COVID-19 Pandemic: Managing Chronic Conditions in a Time of Crisis. Journal of Healthcare Management. 2021;66(4):203–211.
- Michielsen L, et al. Primary healthcare competencies needed in the management of person- centred integrated care for chronic illness and multimorbidity: Results of a scoping review. BMC Primary Care. 2023;24:
98 . DOI: 10.1186/s12875-023-02050-4 - González-Bueno J, Calvo-Cidoncha E, Sevilla-Sanchez D, et al. Patient-Centered Prescription Model to improve therapeutic adherence in patients with multimorbidity. Farmacia Hospitalaria. May 2018;42(3):128–134. DOI: 10.7399/fh.10961
- Gavalda-Espelta E, Lleixa-Fortuño M, Baucells-Lluis J, et al. Innovative Health and Social Integrated Care Model Effectiveness to Improve Quality Care for Chronic Patients: A single group assignment clinical trial. IJIC. 2023;23(4):
2 . DOI: 10.5334/ijic.6759 - Sowden S, Nezafat Maldonado B, Beyer F, Bell W, Lambert M, Thomson R, et al. What works to reduce socioeconomic inequalities in hospitalisations and readmissions? Systematic review of the equity impacts of population-level, health service and integrative interventions. BMJ Public Health. 2025;3:
e002595 . DOI: 10.1136/bmjph-2025-002595 - WHO. Universal Health Coverage fact sheet:
https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc) . Accessed 24 February 2026. - Multimorbidity: a priority for global health research. Academy of Medical Sciences, London, England; 2018.
https://acmedsci.ac.uk/file-download/82222577 - Valentijn P, Schepman S, Opheij W, et al. Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. International journal of integrated care.
https://ijic.org/articles/10.5334/ijic.886 - Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012;380(9836):37–43.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60240-2/fulltext - Chew NWS, Mehta A, Goh RSJ, et al. Cardiovascular–Liver–Metabolic Health: Recommendations in Screening, Diagnosis, and Management of Metabolic Dysfunction-Associated Steatotic Liver Disease in Cardiovascular Disease via Modified Delphi Approach. Circulation. 2025;151:98–119. DOI: 10.1161/CIRCULATIONAHA.124.070535
- Mendoza-Quispe D, Perez-Leon S, Alarcon-Ruiz CA, Gaspar A, Cuba-Fuentes MS, Zunt JR, Montori VM, Bazo-Alvarez JC, Miranda JJ. Scoping review of measures of treatment burden in patients with multimorbidity: advancements and current gaps. J Clin Epidemiol. 2023;159:92–105. DOI: 10.1016/j.jclinepi.2023.05.013
- OECD. Health for the People, by the People. Building People-centred Health Systems; 2021.
https://www.oecd.org/en/publications/health-for-the-people-by-the-people_c259e79a-en.html - Auschra C. Barriers to the Integration of Care in Inter-Organisational Settings: A Literature Review. 2018. International Journal of Integrated Care. 18(1):
5 .https://ijic.org/articles/10.5334/ijic.3068 - Lee J, Lee J, Shin R, et al. Treatment burden in multimorbidity: an integrative review. BMC Prim. Care. 2024;25:
352 . DOI: 10.1186/s12875-024-02586-z - Boehmer K, Gionfriddo M, Rodriguez-Gutierrez R, et al. Patient capacity and constraints in the experience of chronic disease: a qualitative systematic review and thematic synthesis. BMC Family Practice. 2016;17:1–23. DOI: 10.1186/s12875-016-0525-9
- Ferro E, Satheesh G, Castellano J, et al. WHF Roadmap on Single Pill Combination Therapies. 2025;20(1):
73 . DOI: 10.5334/gh.1457 - Vidyasagaran A, et al. COSMOS collaboration. Core outcome sets for trials of interventions to prevent and to treat multimorbidity in adults in low and middle-income countries: the COSMOS study. BMJ Glob Health. 2024 Aug 19;9(8):
e015120 . PMID: 39160083; PMCID: PMC11340216. DOI: 10.1136/bmjgh-2024-015120 - ACC News Story. Nov 2025. POLY-HF: Daily Polypill Boosts Heart Function, QOL, and Cuts Hospitalizations in Underserved Patients With HFrEF. Accessed 26 January 2026:
https://www.acc.org/latest-in-cardiology/articles/2025/11/03/16/19/mon-1045am-polyhf-aha-2025 - WHO. Framework on integrated, people-centred health services; 2016.
https://apps.who.int/gb/ebwha/pdf_files/wha69/a69_39-en.pdf . Accessed 23 January 2026. Integrated Care: Reflections on Change in Health Services . Axel Kahn. Emerald Publishing Limited. DOI: 10.1108/9781801179782- Kendir C, et al.
“PROMoting quality of care through patient reported outcome measures (PROMs): Systematic collection of PROMs for quality improvement and assurance in 38 countries” . OECD Health Working Papers. 2025;183 . OECD Publishing, Paris. DOI: 10.1787/c17bb968-en - Rico, et al. 2021 Kaman Fan, Yi Zhao, Mobile health technology: a novel tool in chronic disease management. Intelligent Medicine. 2022;2(1):41–47. ISSN 2667-1026. DOI: 10.1016/j.imed.2021.06.003
- OECD. Integrating Care to Prevent and Manage Chronic Diseases: Best Practices in Public Health, OECD Publishing, Paris; 2023. Accessed 24 January 2026. DOI: 10.1787/9acc1b1d-en
- Yang Y, Hoo J, Tan J, et al. Multicomponent integrated care for patients with chronic heart failure: systematic review and meta-analysis. ESC Heart Failure. 2023;10:791–807. DOI: 10.1002/ehf2.14207
- Rocks S, Berntson D, Gil-Salmerón A, et al. Cost and effects of integrated care: a systematic literature review and meta-analysis. Eur J Health Econ. 2020 Nov;21(8):1211–1221. Epub 2020 Jul 6. PMID: 32632820; PMCID: PMC7561551. DOI: 10.1007/s10198-020-01217-5
Medication Safety in Polypharmacy . Geneva: World Health Organization; 2019 (WHO/UHC/SDS/2019.11). Licence: CC BY-NC-SA 3.0 IGO.- Coyle M, Davis M, Langley M. Integrated Care during the COVID-19 Pandemic: Managing Chronic Conditions in a Time of Crisis. Journal of Healthcare Management. 2021;66(4):203–211.
- Garfan S, Alamoodi AH, Zaidan BB, et al. Telehealth utilization during the COVID-19 pandemic: A systematic review. Inform Med Unlocked. 2021;24:
100564 . Computers in Biology and Medicine. 2021;138:104878. ISSN 0010-4825. DOI: 10.1016/j.compbiomed.2021.104878 - Kraef C, van der Meirschen M, Free C. Digital telemedicine interventions for patients with multimorbidity: a systematic review and meta-analysis. BMJ Open. 2020 Oct 13;10(10):
e036904 . PMID: 33051232; PMCID: PMC7554457. Parks et al., 2020. DOI: 10.1136/bmjopen-2020-036904 - Tromp J, Jindal D, Redfern J, Bhatt A, Séverin T, et al. World Heart Federation Roadmap for Digital Health in Cardiology. Global Heart. 2022;17(1):
59 . DOI: 10.5334/gh.1141 - Mounier-Jack S, Mayhew S, Mays N. Integrated care: learning between high-income, and low- and middle-income country health systems, Health Policy and Planning. November 2017;32(suppl_4):iv6–iv12. DOI: 10.1093/heapol/czx039
What do we know about community health workers? A systematic review of existing reviews . Geneva: World Health Organization; 2020 (Human Resources for Health Observer Series No. 19). Licence: CC BY- NC-SA 3.0 IGO.https://creativecommons.org/licenses/by-nc-sa/3.0/igo - Endalamaw A, Zewdie A, Wolka E, et al. Care models for individuals with chronic multimorbidity: lessons for low- and middle-income countries. BMC Health Serv Res. 2024;24:
895 . DOI: 10.1186/s12913-024-11351-y - de Koeijer R, de Geest, M, Hajer G, et al. Regional Integrated Cardiovascular Risk Management Care Pathway in the Netherlands: Benefits and Working Mechanisms. International Journal of Integrated Care. 2025;25(3):
1 . DOI: 10.5334/ijic.8654 - Valentijn PP, Tymchenko L, Gruisen W, et al. Effectiveness of Integrated Care for Diabetes Mellitus Type 2, Cardiovascular and Chronic Respiratory Diseases: A Systematic Review and MetaAnalysis. International Journal of Integrated Care. 2024;24(3):
16 , 1–18. DOI: 10.5334/ijic.7744 - Raaijmakers L, et al. Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study. Int. J. Environ. Res. Public Health. 2023;20(5):
3824 . DOI: 10.3390/ijerph20053824 - PAHO. Global Hearts Initiative. Anon (2024). HEARTS in the Americas. Compendium of essential clinical tools. 2023;
15 .https://iris.paho.org/handle/10665.2/59164 - Chew NWS, Mehta A, Goh RSJ, et al. Cardiovascular–Liver–Metabolic Health: Recommendations in Screening, Diagnosis, and Management of Metabolic Dysfunction-Associated Steatotic Liver Disease in Cardiovascular Disease via Modified Delphi Approach. Circulation. 2025;151:98–119. DOI: 10.1161/CIRCULATIONAHA.124.070535
- Leijten F, Struckmann V, van Ginneken E, et al. The SELFIE framework for integrated care for multi-morbidity: Development and description. Health Policy. 2018;122(1):12–22. ISSN 0168-8510. DOI: 10.1016/j.healthpol.2017.06.002
- Lin J, Islam K, Leeder S, et al. (2022) Integrated Care for Multimorbidity Population in Asian Countries: A Scoping Review. International Journal of Integrated Care. 22(1):
22 . DOI: 10.5334/ijic.6009 - The nine pillars of integrated care:
https://integratedcarefoundation.org/nine-pillars-of-integrated-care - Asweto C, Alzain M, Andrea S, et al. Integration of community health workers into health systems in developing countries: Opportunities and challenges. BMJ Family Medicine and Community Health. 2016;
4 . DOI: 10.15212/FMCH.2016.0102 - Shah B, Allen J, Chaudhury H, et al. The role of digital health in the future of integrated care. Clinics in Integrated Care. 2022;15:
100131 . ISSN 2666-8696. DOI: 10.1016/j.intcar.2022.100131 - Meder B, Asselbergs F, Ashley E. Artificial intelligence to improve cardiovascular population health. European Heart Journal. 21 May 2025;46(20):1907–1916. DOI: 10.1093/eurheartj/ehaf125
- Amelung V, Cheah J. Is There an Ideal Payment Model That Enables Integrated Care: Searching for the Impossible? Editorial. Int J Integr Care. 2024 Nov 22;24(4):
10 . DOI: 10.5334/ijic.9029 - WHO.
Role of purchasing arrangements for quality chronic care: scoping review . Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.https://www.who.int/publications/i/item/9789240084919 - Amelung V.
Handbook Integrated Care . 2nd Edition. 2021. Springer. pp. 341–376.https://link.springer.com/book/10.1007/978-3-030-69262-9 - Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan. 1994 Dec;9(4):353–70. PMID: 10139469. DOI: 10.1093/heapol/9.4.353
- Yordanov D, Oxholm AS, Prætorius T, Kristensen SR. Financial incentives for integrated care: A scoping review and lessons for evidence-based design. Health Policy. 2024;141:
104995 . DOI: 10.1016/j.healthpol.2024.104995 - Labrique AB, Wadhwani C, Williams KA, et al. Best practices in scaling digital health in low- and middle-income countries. Global Health. 2018;14:
103 . DOI: 10.1186/s12992-018-0424-z - Fullaondo A, Hamu Y, Txarramendieta J, et al. Scaling-Out Digitally Enabled Integrated Care in Europe Through Good Practices Transfer: The JADECARE Study. International Journal of Integrated Care. 2024;24(3):
15 . DOI: 10.5334/ijic.8605 - World Bank. Digital-in-Health: Unlocking the Value for Everyone. World Bank; 2023.
http://hdl.handle.net/10986/40212 License: CC BY 4.0.https://openknowledge.worldbank.org/entities/publication/06ffb4d1-a7c0-4563-9feb-f14fa8395e32 - Scholte T, Gürgöze M, Aydin D, et al. Telemonitoring for heart failure: a meta-analysis. European Heart Journal. 14 August 2023;44(31):2911–2926. DOI: 10.1093/eurheartj/ehad280
- Miao Y, Luo Y, Zhao Y, et al. Effectiveness of eHealth Interventions in Improving Medication Adherence Among Patients With Cardiovascular Disease: Systematic Review and Meta-Analysis. J Med Internet Res. 2024;26:
e58013 . DOI: 10.2196/58013 - Fairbairn T, Mullen L, Nicol E, et al. Implementation of a national AI technology program on cardiovascular outcomes and the health system. Nat Med. 2025;31:1903–1910. DOI: 10.1038/s41591-025-03620-y
- van der Vegt A, Campbell V, Mitchell I, et al. Systematic review and longitudinal analysis of implementing Artificial Intelligence to predict clinical deterioration in adult hospitals: what is known and what remains uncertain. Journal of the American Medical Informatics Association. February 2024;31(2):509–524. DOI: 10.1093/jamia/ocad220
- Wieland-Jorna Y, van Kooten D, Verheij RA, et al. Natural language processing systems for extracting information from electronic health records about activities of daily living. A systematic review. JAMIA Open. 2024 May 24;7(2):
ooae044 . PMID: 38798774; PMCID: PMC11126158. DOI: 10.1093/jamiaopen/ooae044 - Tromp J, Seekings PJ, Hung C-L, Iversen MB, Frost MJ, Ouwerkerk W, et al. Automated interpretation of systolic and diastolic function on the echocardiogram: a multicohort study. Lancet Digit Heal. 2021; Accepted. DOI: 10.1016/S2589-7500(21)00235-1
- Abuzour AS, Wilson SA, Woodall AA, et al. Developing an AI-Assisted Tool That Identifies Patients With Multimorbidity and Complex Polypharmacy to Improve the Process of Medication Reviews: Qualitative Interview and Focus Group Study. J Med Internet Res. 2026;28:
e74304 . DOI: 10.2196/74304 - Meder B, Asselbergs FW, Ashley E. Artificial intelligence to improve cardiovascular population health. European Heart Journal. 21 May 2025;46(20):1907–1916. DOI: 10.1093/eurheartj/ehaf125
- Singh K, Nashwan A. Artificial Intelligence-driven solutions: revolutionizing patient care in multimorbidity management. Discov Health Systems. 2025;4:
65 . DOI: 10.1007/s44250-025-00251-5 - WHO. The ongoing journey to commitment and transformation. Digital Health in the WHO European Region 2023. ISBN: 978-92-890-6022-6 (PDF). WHO 2023.
https://cdn.who.int/media/docs/librariesprovider2/data-and-evidence/english-ddh-260823_7amcet.pdf?sfvrsn=4c674522_2&download=true - Abernethy A, Adams L, Barrett M, et al. The Promise of Digital Health: Then, Now, and the Future. NAM Perspect. 2022 Jun 27;2022:10.31478/202206e. DOI: 10.31478/202206e
- Menear M, Blanchette MA, Demers-Payette O, et al. A framework for value-creating learning health systems. Health Res Policy Sys. 2019;17:
79 . DOI: 10.1186/s12961-019-0477-3 - WHO. Continuity and coordination of care. A practice brief to support implementation of the WHO Framework on integrated people-centred health services; 2018.
https://integratedcarefoundation.org/wp-content/uploads/2018/08/WHO-practice-brief-on-continuity-and-coordination-of-care.pdf Accessed 24 January 2026. - WHO. Nolte E, Pitchforth E. 2014. WHO. What is the evidence on the economic impacts of integrated care? PDF.
https://iris.who.int/bitstreams/91f3ca3b-ceab-4a4d-a087-c8d5c41ec25d/download Accessed 24 January 2026. - Batterham RW, Hawkins M, Collins P, et al. Health literacy: applying current concepts to improve health services and reduce health inequalities. Public Health. 2016;132:3–12. DOI: 10.1016/j.puhe.2016.01.001
- Fitzpatrick P. Improving health literacy using the power of digital communication tools to achieve better health outcomes for patients and practitioners. Front Digit Health. 2023 Nov 17;5:
1264780 . DOI: 10.3389/fdgth.2023.1264780 - Bayliss E, Ellis J, Steiner F. Barriers to self-management and quality-of-life outcomes in seniors with multimorbidities. Annals of Family Medicine. 2007;5(5):395–402. DOI: 10.1370/afm.722
- Struckmann V, Quentin W, Busse R, et al. ICARE4U consortium. 2017. How to strengthen mechanisms to promote care for people with multimorbidity in Europe?
http://www.icare4eu.org/pdf/PB_24.pdf Accessed 24 January 2026. - Banerjee A, Hurst J, Fottrell E, Miranda JJ. Multimorbidity: Not Just for the West. Glob Heart. 2020 Jul 2;15(1):
45 . PMID: 32923339; PMCID: PMC7413145. DOI: 10.5334/gh.835 - OECD. Does healthcare deliver? Results from the Patient-Reported Indicator Surveys (PaRIS); 2025. PDF.
https://www.oecd.org/en/publications/does-healthcare-deliver_c8af05a5-en.html - Basto-Abreu A, Barrientos-Gutierrez T, Wade AN, et al. Multimorbidity matters in low and middle-income countries. J Multimorb Comorb. 2022 Jun 16;12:
26335565221106074 . PMID: 35734547; PMCID: PMC9208045. DOI: 10.1177/26335565221106074 - Seneviratne S, Desloge A, Oldenburg B. Characteristics and Outcomes of Community Health Worker Training to Improve the Prevention and Control of Cardiometabolic Diseases in Low and Middle-Income Countries: A Systematic Review. Inquiry. 2022 Aug 2;59:
00469580221112834 . DOI: 10.1177/00469580221112834 - Muche-Borowski C, Lühmann D, Schäfer I, et al. Development of a meta-algorithm for guiding primary care encounters for patients with multimorbidity using evidence-based and case-based guideline development methodology. BMJ Open 2017;7:
e015478 . DOI: 10.1136/bmjopen-2016-015478 - O’Donovan J, O’Donovan C, Kuhn I, et al. Ongoing training of community health workers in low-income and middle-income countries: a systematic scoping review of the literature. BMJ Open. 2018;8:
e021467 . DOI: 10.1136/bmjopen-2017-021467 - Macinko J, Harris MJ. Brazil’s family health strategy – delivering community-based primary care in a universal health system. N Engl J Med. 2015;372:2177–2181. DOI: 10.1056/NEJMp1501140
- Kruk M, Gage A, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health, 2018;6(11):e1196–e1252. DOI: 10.1016/S2214-109X(18)30386-3
- Suter E, Oelke N, Stiphout M.
Chapter: Tools and Frameworks to Measure Health System Integration . In: Amelung V, Stein V. Handbook of Integrated Care. Springer, Cham; 2025. DOI: 10.1007/978-3-031-25376-8_32-1 Health systems resilience toolkit: a WHO global public health good to support building and strengthening of sustainable health systems resilience in countries with various contexts . Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO:https://iris.who.int/server/api/core/bitstreams/5dee789f-c197-4d45-b1aa-391da7b8bcf8/content - Proctor EK, Landsverk J, Aarons G, et al. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Adm Policy Ment Health. 2009 Jan;36(1):24–34. Epub 2008 Dec 23. PMID: 19104929; PMCID: PMC3808121. DOI: 10.1007/s10488-008-0197-4
- Proctor EK, Silmere H, Raghavan R. et al. Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Adm Policy Ment Health. 2011;38:65–76. DOI: 10.1007/s10488-010-0319-7
- Health at a Glance: Data and Digital. OECD/WHO; 2025:
https://www.oecd.org/en/publications/2025/11/health-at-a-glance-2025_a894f72e/full-report/data-and-digital_fd9fbb54.html Accessed 24 January 2026. - Smith L, Simpson G, Holt S, et al. Digital applications to support self-management of multimorbidity: A scoping review. 2025. International Journal of Medical Informatics. 2025;202:
105988 . DOI: 10.1016/j.ijmedinf.2025.105988 - Friedman C, Rubin J, Brown J, et al. Toward a science of learning systems: a research agenda for the high-functioning Learning Health System. J Am Med Inform Assoc. 2015 Jan;22(1):43–50. Epub 2014 Oct 23. PMID: 25342177; PMCID: PMC4433378. DOI: 10.1136/amiajnl-2014-002977