Patients with multimorbidity are becoming the norm rather than the exception. The management of patients with several chronic diseases is now the most important challenge facing health care systems in developed countries. Based on the actual medical records of ambulatory care visits, this study investigated the prevalence and patterns of multimorbidity in 55 and older population. Among a cohort comprised of 300,000 beneficiaries selected randomly from the National Health Insurance Research Database of Taiwan in 2001, 42,441 were eligible. These were followed longitudinally 10 years. The prevalence of chronic disease rose from 62.3% to 79.8% and multimorbidity rose from 57.4% to 75.7%. Multimorbidity patterns were found fell in-to four clusters: metabolic diseases, cardiac diseases, mental joints and gastrointestinal tract disorders. Hypertension and diabetes mellitus, as well as hyperplasia of the prostate in men, were the most common chronic diseases. The prevalence of chronic disease increased with age, especially high at age 75 - 79. Thought about the health care system for an ageing society is necessary. Applying the concept of customer experience and strengthening people-centered management in an integrated model of health care, enhancing knowledge and skills in the long-term management of chronic disease, revising clinical guidelines and training professionals in caring for the elderly, reinforcing preventive health services, especially in men’s health, modifying the materials for health education, and planning for health manpower resources will provide a better model to ensure the health care for people with multimorbidity.
Worldwide, the rapidly ageing population is a major global public health challenge to be faced in the 21st Century. According to the World Health Organization [
Ageing is associated with an exponential increase in multimorbidity [
The current design of the medical care system is oriented mainly toward acute care. With the rapid ageing of the population, this will require the transformation of health care systems away from disease-based curative models and towards the provision of older-person-centered and integrated care. Medical outcomes need to be considered throughout the course of treatment. This usually involves multiple professional interventions from diagnosis and treatment to the sustainable management of patients [
The aims of this study were: 1) to investigate the trends in chronic diseases and the distribution of multimorbidity in the older adult population; 2) to examine the patterns of multimorbidity in that population; and 3) to analyze the differences in patterns of multimorbidity in terms of age or gender. These findings may then influence the government in making health policy decisions, redesigning the health care system, and determining the timing of policy interventions and the priority of medical resource allocation to ensure the achievement of patient-centered care within a global health paradigm.
The data used in this study were taken from the National Health Insurance Research Database (NHIRD) which was constructed by the National Health Research Institutes (NHRI). Each year, the National Health Insurance Administration, Ministry of Health and Welfare (NHIA, MOHW) collects data from the National Health Insurance (NHI) program and sorts it into data files which include registration files and original claim data for reimbursement. These data files are de-identified by scrambling the identification codes of patients and care providers, including medical institutions/facilities and physicians, and then sent to the NHRI to make up the original files of NHIRD. The data are further scrambled before being released to researchers who wish to use the NHIRD and its data subsets. Each researcher is required to sign a user agreement declaring that she/he has no intent to attempt to obtain information that could potentially violate the privacy of patients or care providers and to acknowledge the NHIRD in their publications [
A longitudinal, person-based approach was used to investigate the trends of patterns of chronic conditions over 10 years for the 55 and older population. According to the NHIRD, a cohort of 1,000,000 beneficiaries was randomly sampled from the NHI registry of beneficiaries from March 1, 1995 to December 31, 2000 (from a total of approximately 23,753,407 persons). Linear congruent random number generation was used to sample the cohort. Patients were followed longitudinally unless they were lost due to death or emigration; and the files were updated annually. There were no significant differences in age, gender, and expense distribution between the sample and the entire population [
The subjects analyzed in this study were 300,000 beneficiaries selected randomly from the cohort of 1,000,000. Of these, 42,441 were 55 years and older. These were followed longitudinally for multimorbidity from 2001 to 2011.
In order to investigate the elderly population suffering from chronic diseases, the following variables were included.
Demographics: Due to the limitations of the database, the only two demographic variables that were analyzed were age and gender. Age was stratified into the following groups: 55 - 59, 60 - 64, 65 - 69, 70 - 74, 75 - 79, 80 - 84, and 85+ for analysis.
Inclusion criteria for chronic diseases were: 1) a primary diagnosis from the International Classification of Diseases, Ninth Revision, Clinical Modification, which fell within the scope of chronic diseases covered by national health insurance; 2) at least 14 days of prescription drug use as an outpatient and two or more visits per year.
Multimorbidity referred to the presence of two or more chronic diseases in one individual.
Descriptive statistics such as percentage and frequency were used to investigate the distribution of study participant characteristics, the trends in chronic disease, and the distribution of multimorbidity. Factor analysis was used to analyze the multimorbidity patterns. Logistic regression and multiple regression were used to analyze the differences in multimorbidity patterns by age and gender. Statistical significance was set at p ≤ 0.05. SPSS 19.0 was used for all analyses.
Of the 42,441 study participants, 49.6% were male and 50.3% were female; the gender of 43 persons was unknown. The 55 - 64 age group accounted for 43.0%; the 65 - 79 age group accounted for 47.3%; and those aged ≥80 accounted for 9.7%. The overall prevalence of chronic disease was 62.3% (
Among the patients with chronic diseases, those with 3 accounted for 20.1% in 2001, 19.4% in 2006, and 18.7% in 2011. The overall prevalence of chronic disease was 62.3% in 2001, 72.1% in 2006, 79.8% in 2011, and the prevalence of multimorbidity was 57.4%, 67.4%, 75.7%, respectively (
Hypertension (ICD-9 code 401) and diabetes mellitus (ICD-9 code 250) were the first and second most common chronic diseases in all three groups (men, women, and all patients) in 2001, 2006, and 2011, except that hyperplasia of the prostate (ICD-9 code 600) was the second most common in men in 2011. Disorders of lipid metabolism (ICD-9 code 272) were the third most common chronic disease in women and in all patients in 2006 and 2011; the next most common chronic disease was osteoarthrosis disorders (ICD-9 code 715). For men, both of these diseases increased over the 10 year period. Hyperplasia of the prostate rose from number 4 up to number 2 for men over the 10 years. Factor analysis showed that these diseases fell into four clusters: metabolic
Variables | No. | % |
---|---|---|
Sex | ||
Male | 21,031 | 49.6 |
Female | 21,367 | 50.3 |
Unknown | 43 | 0.1 |
Age | ||
55 - 59 | 8904 | 21.0 |
60 - 64 | 9327 | 22.0 |
65 - 69 | 7946 | 18.7 |
70 - 74 | 7200 | 17.0 |
75 - 79 | 4942 | 11.6 |
80 - 84 | 2597 | 6.1 |
85+ | 1525 | 3.6 |
All patients | 42,441 | 100 |
Chronic condition | ||
Yes | 26,431 | 62.3 |
No | 16,010 | 37.7 |
No of chronic disease | 2001 | 2006 | 2011 |
---|---|---|---|
% | % | % | |
1 | 7.8 | 6.5 | 5.1 |
2 | 12.9 | 11.0 | 8.8 |
3 | 20.1 | 19.4 | 18.7 |
4 | 14.4 | 13.8 | 12.7 |
5 | 12.1 | 11.8 | 12.1 |
6 | 9.4 | 10.1 | 10.5 |
7 | 6.8 | 7.2 | 8.1 |
8 | 5.1 | 5.7 | 6.2 |
9 | 3.6 | 4.2 | 4.9 |
10 | 2.5 | 3.0 | 3.5 |
Accumulate (%) | 94.7 | 92.7 | 90.6 |
All patients | 42,441 | 36,706 | 31,240 |
Yes/chronic disease | 26,431 | 26,464 | 24,931 |
Prevalence of chronic disease | 62.3 | 72.1 | 79.8 |
Prevalence of multimorbidity | 57.4 | 67.4 | 75.7 |
diseases (hypertension, diabetes, and lipid disorders); cardiac diseases (hypertensive heart disease (ICD-9 code 402) and chronic ischemic disease (ICD-9 code 414)); mental joints (osteoarthrosis disorders, general symptom (ICD-9 code 780), and neurotic disorders (ICD-9 code 300)); and gastrointestinal tract disorders (functional digestive disorders (ICD-9 code 564) and functional stomach disorders (ICD-9 code 536)) (
ICD-9 code | 2001 | 2006 | 2011 | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
% | Ranking | % | % | Ranking | % | % | Ranking | % | |||||||
Male | Male | All | Female | Female | Male | Male | All | Female | Female | Male | Male | All | Female | Female | |
401 | 41.6 | 1 | 1 | 1 | 42.5 | 48.0 | 1 | 1 | 1 | 51.8 | 51.4 | 1 | 1 | 1 | 55.3 |
250 | 22.0 | 2 | 2 | 2 | 24.6 | 24.7 | 2 | 2 | 2 | 28.3 | 27.4 | 3 | 2 | 2 | 30.8 |
402 | 21.6 | 3 | 3 | 3 | 22.3 | 19.0 | 4 | 4 | 5 | 21.4 | 17.2 | 6 | 6 | 6 | 19.1 |
715 | 12.6 | 9 | 4 | 4 | 18.6 | 16.5 | 8 | 5 | 4 | 23.6 | 18.2 | 5 | 4 | 4 | 25.7 |
414 | 16.4 | 5 | 5 | 8 | 14.4 | 16.8 | 6 | 7 | 8 | 15.3 | 17.0 | 8 | 7 | 8 | 14.3 |
780 | 13.6 | 7 | 6 | 5 | 16.6 | 16.7 | 7 | 6 | 6 | 21.3 | 17.2 | 6 | 5 | 5 | 20.8 |
564 | 16.0 | 6 | 7 | 10 | 13.3 | 15.5 | 9 | 8 | 9 | 13.0 | 16.1 | 9 | 8 | 9 | 12.9 |
272 | 12.3 | 10 | 8 | 6 | 15.8 | 17.6 | 5 | 3 | 3 | 24.0 | 22.8 | 4 | 3 | 3 | 30.2 |
536 | 13.4 | 8 | 9 | 9 | 13.5 | 8.5 | 10 | 8.9 | 6.7 | 10 | 7.2 | ||||
300 | 10.9 | 10 | 7 | 15.6 | 10.6 | 10 | 9 | 7 | 15.9 | 9.7 | 10 | 10 | 7 | 14.5 | |
600 | 19.6 | 4 | 0.0 | 24.3 | 3 | 10 | 0.0 | 30.4 | 2 | 9 | 0.0 | ||||
Factor analysis | |||||||||||||||
Factor 1 | 401,250,272 | 401,250,272 | 250,272 | ||||||||||||
Factor 2 | 402,414 | 402,414 | 401,402,414 | ||||||||||||
Factor 3 | 715,780,300 | 715,780,300 | 715,780,300 | ||||||||||||
Factor 4 | 564,536 | 564,536 | 564,536 |
Variables | Logistic regression | Multiple regression | ||||
---|---|---|---|---|---|---|
Yes/no chronic condition | Dependent variables | |||||
Odds ratio | No. of chronic condition | |||||
2001 | 2006 | 2011 | 2001 | 2006 | 2011 | |
(Constant) | 0.92*** | 1.45*** | 2.24*** | 3.90*** | 4.45*** | 0.52*** |
Sex | ||||||
Male | 1.00 | 1.00 | 1.00 | 0.00 | 0.00 | 0.00 |
Female | 1.23*** | 1.21*** | 1.32*** | 0.21*** | 0.02 | −0.16*** |
Age | ||||||
55 - 59 | 1.00 | 1.00 | 1.00 | 0.00 | 0.00 | 0.00 |
60 - 64 | 1.30*** | 1.30*** | 1.40*** | 0.38*** | 0.40*** | 0.36*** |
65 - 69 | 1.80*** | 2.08*** | 2.14*** | 0.84*** | 0.87*** | 0.82*** |
70 - 74 | 2.33*** | 2.60*** | 2.46*** | 1.30*** | 1.35*** | 0.98*** |
75 - 79 | 2.64*** | 2.68*** | 2.28*** | 1.48*** | 1.42*** | 0.98*** |
80 - 84 | 2.42*** | 2.69*** | 2.08*** | 1.30*** | 1.14*** | 0.67*** |
85+ | 1.92*** | 1.93*** | 1.36 | 1.23*** | 1.19*** | 0.38 |
*p < 0.05; **p < 0.01; ***p < 0.001.
To the best of our knowledge, this was the first study to use a person-based longitudinal analysis to investigate the trend in patterns of chronic diseases in a population aged 55 and over, over a period of 10 years. The main findings were: The prevalence of chronic disease rose from 62.3% to 79.8% and multimorbidity rose from 57.4% to 75.7%. Multimorbidity patterns were found fell into four clusters: metabolic diseases (hypertension, diabetes, and lipid disorders); cardiac diseases (hypertensive heart disease and chronic ischemic disease); mental joints (osteoarthrosis disorders, general symptom, and neurotic disorders); and gastrointestinal tract disorders (functional digestive disorders and functional stomach disorders). Hypertension and diabetes mellitus, as well as hyperplasia of the prostate in men, were the most common chronic diseases in the population aged 55 and over. Women were more susceptible to chronic diseases than were men. The prevalence of chronic disease increased with age, and was especially high among those who were 75 - 79.
In this study, a 55 and older cohort was followed for 10 years, and the prevalence of chronic disease and multimorbidity grew from 62.3% to 79.8% and 57.4% to 75.7%, respectively. A previous study showed that the prevalence of multimorbidity was 55% to 98% [
With regard to patterns of multimorbidity, the results of this study found four clusters including metabolic diseases (hypertension, diabetes, and lipid disorders);cardiac diseases (hypertensive heart disease and chronic ischemic disease); mental joints (osteoarthrosis disorders, general symptom, and neurotic disorders); and gastrointestinal tract disorders (functional digestive disorders and functional stomach disorders). Despite the methodological variability among studies, the review by Prados-Torres et al. [
Disorders of lipid metabolism and osteoarthrosis disorders accompanied by hypertension and diabetes were the most common chronic disease cluster in women and in all patients. Schram et al. [
We found a trend towards higher prevalence rates of chronic diseases with increasing age, especially among those who were 75 - 79. This was consistent with most studied [
In agreement with findings from other studies, our findings indicated that the prevalence of chronic conditions among women was higher than that among men. Interestingly, over the 10 year period, the number of chronic diseases in men was greater than that in women. In general, women are more sensible than men, are prone to express feelings easily, and show a greater awareness of health problems and symptoms. Therefore, they often have better perceptions about their own health and suffer from non-fatal condition that can be taken care of in primary healthcare settings [
In this study, we conducted a person-based longitudinal analysis to investigate the trend in patterns of chronic conditions and multimorbidity in population aged 55 and over, over a 10 year period. This reflected chronic situations more accurately and thus avoided potential recall biases using other methods of data collection (e.g., questionnaires).
There are some limitations to this study. First, the demographic variables in the analyses were limited to age and gender. Other variables, such as region, income, and educational level, were not considered. Second, the subjects analyzed in this study were a closed study population, some of whom may have moved or died during the10 year follow-up and were not included in the statistics. Third, data were based on ICD-9 coding, and the diagnostic ability of physicians, the validity of coding, and the severity of disease were additional unknowns. Future studies might further analyze the relationship between the patterns of disease, multi-morbidity, region, and hospital level, or link to the database on mortality to identify the impact of the cause of death on medical resources.
Compared with the previous literature which focused on cross-sectional or self-reported past history studies, this study used a cohort of 55 and older population followed for 10 years, and actual medical records were utilized to analyze the trends in patterns of chronic conditions and multimorbidity. The results clearly demonstrated that there were gender and age differences, as women were more susceptible to developing chronic diseases, and there was a trend towards higher prevalence rates for multimorbility with increasing age, especially among those who were 75 - 79. Hypertension and diabetes mellitus, and hyperplasia of the prostate in men, were the most common chronic diseases. Based on the patterns of multimorbidity, it is necessary to rethink the health care system in order to meet the needs of the elderly. Applying the concept of customer experience and strengthening people-centered management in an integrated model of health care, enhancing knowledge and skills in the long-term management of chronic disease, revising clinical guidelines and training professionals in caring for the elderly, reinforcing preventive health services, especially in men’s health, modifying the materials for health education, and planning for health manpower resources will provide a better model for public health and medical care within a global health paradigm.
This study is based in part on data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health and managed by National Health Research Institutes in Taiwan. The interpretation and conclusions contained herein do not represent those of Bureau of National Health Insurance, Department of Health or National Health Research Institutes.
The authors declared no potential conflict of interest in this study.
This study was supported by grants from the National Taiwan University Hospital, Hsin-Chu Branch, (HCH103-065).
Wang, M.-J. and Lo, Y.-T. (2016) Thoughts about Person- Centered Care for the Adult Population with Multimorbidity. Health, 8, 1275-1287. http://dx.doi.org/10.4236/health.2016.812130