Multimorbidity in clinical practice

Main Article Content

D. D. Dyachuk
G. Z. Moroz
I. M. Hydzynska
T. S. Lasitsya


Multimorbidity is defined as two or more chronic conditions in the same individual. It is associated with significant impacts on quality of life, poor functional status, enhancement of the challenges of medical care and cost implications, unnecessary hospitalizations, increases the terms of hospital stay, and affects the evaluation of the interventions effectiveness. The article reviews the prevalence of multimorbidity, combinations of conditions in people with multimorbidity, especially, in patients with cardiovascular diseases. This review also identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities as presented in WHO manual, Guiding principles for the care of older adults with multimorbidity of the American Geriatrics Society and NICE clinical guidelines (NG56). The paper outlined key problems posed by current healthcare organization and experienced by patients with multimorbidity – the need for the development of accurate and reliable methods of comorbidity assessment and evidence-based outcome measurement criteria and tools.

Article Details


мультиморбідність, коморбідність, індекси коморбідності, серцево-судинні захворювання, медична допомога пацієнтам з коморбідністю


Bukach OP, Antonyuk MV, Sydorchuk LP, Korovenkova OM, Kushnir OV, Chahliy II. Comorbidity in patients with arterial hypertension in ambulatory-policlinic practice. Bukovynskyy medychnyy visnyk [Bukovinsky Medical Bulletin]. 2013;4(68):26–31. (in Ukr.)

Kolomoyets MYu, Vashenyak OO. Comorbidity and polymorbidity in therapeutic practice. Ukr. med. Chasopys [Ukr medical journal]. 2012;4(90):23–27. (in Ukr.)

Nesen AO, Chyrva OV, Valentynova IA, Hrunchenko MM, Shkapo VL. Comorbid pathological conditions in patients with high cardiovascular risk. Ukrayinskyy zhurnal medytsyny, biolohiyi ta sportu [Ukrainian Journal of Medicine, Biology and Sports]. 2016;2(2):147–150. (in Ukr.)

Nurgazizova AK. The origin, development and modern interpretation of the concepts of "comorbidity" and "polymorbidity". Kazanskiy meditsinskiy zhurnal [Kazan Medical Journal]. 2014;2:292–296.

Parkhomenko OM, Lutay YaM, Danshan N. Ukrainian registry of acute myocardial infarction as a fragment of the European: patient characteristics, organization of medical care and hospital therapy. Ukraí̈ns'kiy medichniy chasopis [Ukrainian Medical Watch Room]. 2011;1:20–24. (in Rus.)

Sumin AN, Korok YeV, Shcheglova AV, Barbarash OL. Comorbidity in patients with coronary heart disease: gender characteristics. Ratsional'naya Farmakoterapiya v Kardiologii [Rational Pharmacotherapy in Cardiology]. 2017;13(5):622–629.

Kovalenkо VM, Kornatskiy VM. Red. Diseases of the circulatory system as a medical and social and socio-political problem: analytical and statistical manual. Kyyiv, 2014. 278 с. (in Ukr.)

Shal'nova SA, Oganov RG, Deyev AD. Combinations of coronary heart disease with other noncommunicable diseases in the adult population: associations with age and risk factors. Kardiovaskulyarnaya Terapiya i Profilaktika [Cardiovascular Therapy and Prevention].2015;4:44–51. (in Rus.)

Almirall J., Fortin M. The coexistence of terms to describe the presence of multiple concurrent diseases. Journal of Comorbidity. 2013;3:4–9.

American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity: Guiding principles for the care of older adults with multimorbidity: an approach for clinicians. J Am Geriatr Soc. 2012;60:E1–25.

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. Lancet. 2012; 380(9836):37–43.

Bell SP, Saraf АA. Epidemiology of Multimorbidity in Older Adults with Cardiovascular Disease. Clin Geriatr Med. 2016;32(2):215–226. doi: 10.1016/j.cger.2016.01.013

Bouchard C, Antunes-Correa LM, Ashley EA, Franklin N, Hwang PM, Mattsson CM, Negrao CE, Phillips SA, Sarzynski MA, Wang PY, Wheeler MT. Personalized preventive medicine: genetics and the response to regular exercise in preventive interventions. Prog Cardiovasc Dis. 2015;57(4):337–46. doi: 10.1016/j.pcad.2014.08.005

Boyd C, Fortin M. Future of multimorbidity research: How should understanding of multimorbidity inform health system design? Public Health Rev. 2010;32(2):451–474.

Boyd CM, Vollenweider D, Puhan MA. Informing evidence-based decision-making for patients with comorbidity: availability of necessary information in clinical trials for chronic diseases. PloS one. 2012;7(8):e41601. – Режим доступу: http: // journal.pone.0041601.

Buurman BM, Hoogerduijn JG, de Haan RJ, Abu-Hanna A, Lagaay AM, Verhaar, HJ, Schuurmans MJ, Levi M, de Rooij SE. Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival and functional decline. PloS one. 2011;6(11):e26951. doi: 10.1371/journal.pone.0026951

Campbell-Scherer D. Multimorbidity: a challenge for evidence-based medicine. Evid Based Med. 2010;15:165–166.

Carvalho AK, Menezes AMB, Camelier A, Rosa FW, Nascimento OA, Perez-Padilla R, Jardim JR. Prevalence of self-reported chronic diseases in individuals over the age of 40 in São Paulo, Brazil: the PLATINO Study Cad. Saúde Pública, Rio de Janeiro. 2012;28(5):905–912.

Chaplin K, Bower P, Man MS, Brookes ST, Gaunt D, Guthrie B, Mann C, Mercer SW, Rafi I, Shaw ARG, Salisbury С. Understanding usual care for patients with multimorbidity: baseline data from a cluster-randomised trial of the 3D intervention in primary care. BMJ Open. 2018; 8: e019845. doi:10.1136/bmjopen-2017-019845.

Charlson M, Pompei P, Ales K, Mackenzie C. A new method for classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383.

Chung JS, Young HN, Moreno MA, Kliems H, Cox ED. Patient-centred outcomes research: brave new world meets old institutional policies. Fam Pract. 2017;34(3):296–300. doi: 10.1093/fampra/cmw129.

Dawes M. Comorbidity: we need a guideline for each patient not a guideline for each disease. Family Practice. 2010;27:1–2.

2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal. 2018;39(Issue 33):3021–3104. – Режим доступу : https://doi/10.1093/eurheartj/ehy339.

Forman DE, Maurer MS, Boyd C, Brindis R, Salive ME, Horne FM, Bell SP, Fulmer T, Reuben DB, Zieman S, Rich MW. Multimorbidity in Older Adults with Cardiovascular Disease. Am Coll Cardiol. 2018;15,71(19): 2149–2161. doi: 10.1016/j.jacc.2018.03.022

Fortin M, Contant E, Savard C, Hudon C, Poitras M-E, José A. Canadian guidelines for clinical practice: an analysis of their quality and relevance to the care of adults with comorbidity. BMC Family Practice. 2011;12:74. – Режим доступу:

Gordon MJ, Churnetski M, Alqahtani H, Rivera X, Kittai A, Amrock SM, James S, Hoff S, Manda S, Spurgeon SE, Choi M, Cohen JB, Persky D, Danilov AV. Comorbidities predict inferior outcomes in chronic lymphocytic leukemia treated with ibrutinib. Cancer. 2018;124(15):3192–3200. doi: 10.1002/cncr.31554.

Holzer BM, Siebenhuener K, Bopp M, Minder CE. Evidence-based design recommendations for prevalence studies on multimorbidity: improving comparability of estimates. Popul Health Metr. 2017;15(1):9. doi: 10.1186/s12963-017-0126-4

Hughes LD, McMurdo ME, Guthrie B. Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing. 2013;42(1):62-9. doi: 10.1093/ageing/afs100.

Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury C. Measures of Multimorbidity and Morbidity Burden for Use in Primary Care and Community Settings: A Systematic Review and Guide. Ann Fam Med 2012;10:134–141. doi:10.1370/afm.1363

Jakovljević M, Ostojić L. Comorbidity and multimorbidity in medicine today: challenges and opportunities for bringing separated branches of medicine closer to each other. Psychiatr Danub. 2013;25(Suppl. 1):18–28.

Kaplan MH, Feinstein AR. The importance of classifying initial co-morbidity in evaluating the outcome of diabetes mellitus. J Chronic Dis. 1974; 27:387–404.

Kastner M, Cardoso R, Lai Y, Treister V, Hamid JS, Hayden L, Wong G, Ivers NM, Liu B, Marr S, Holroyd-Leduc J, Straus SE. Effectiveness of interventions for managing multiple high-burden chronic diseases in older adults: a systematic review and metaanalysis. CMAJ, 2018;190:E1004-12

Kilby P, Osborn IV, Nothelle S, Slaven James E, Montz K, Hui Siu, Torke AM. Cumulative Illness Rating Scale (CIRS) can be Used to Predict Hospital Outcomes in Older Adults. J Geriatr Med Gerontol. 2017;3:030. doi: 10.23937/2469-5858/1510030

Kingston A, Robinson L, Booth H, Knapp M, Jagger C. Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Age and Ageing, 2018; 47:374–380.

Lee PG, Cigolle C, Blaum C. The Co-Occurrence of Chronic Diseases and Geriatric Syndromes: The Health and Retirement Study. Journal of the American Geriatrics Society. 2009;57(3):511–516.

Lefevre Т, d’Ivernois JF, De Andrade V, Crozet C, Lombrail P, Gagnayre R. What do we mean by multimorbidity? An analysis of the literature on multimorbidity measures, associated factors, and impact on health services organization. Revue d’Epidemiologie et de Sante Publique. 2014;62:305–314.

Medicine optimisation: Quality Standard № 120. 2016. – Режим доступу:

Meraer SW, Gunn J, Wyke S. Improwing the health of people with multimorbidity: the need for prospective cohort studies. J. Comorbidity. 2011;1: 4–7.

Mercer SW, Zhou Y, Humphris GM, McConnachie A, Bakhshi A, Bikker A, Higgins M, Little P, Fitzpatrick B, Watt GCM. Multimorbidity and Socioeconomic Deprivation in Primary Care Consultations. Ann Fam Med., 2018; 16:127–131.

Millar E, Stanley J, Gurney J, Stairmand J, Davies C, Semper, K, Dowwell A, Lawrenson R, Mangin D, Sarfati D. Effect of multimorbidity on health service utilisation and health care experiences. Journal of Primary Health Care, 2018;10(1):44–53.

Multimorbidity: clinical assessment and management NICE guideline (NG56) 2016:

Multimorbidity: Quality Standard № 153. – Режим доступу:

Multimorbidity: Technical Series on Safer Primary Care. – Geneva: World Health Organization, 2016. – Licence: CC BY-NC-SA 3.0 IGO.

Multimorbidity: a priority for global health research. Academy of Medical Sciences Report. 2018:

Multiple Chronic Conditions – A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions / U.S. Department of Health and Human Services. – Washington, DC, 2010.

Navickas R, Petric VK, Feigl AB, Seychell M. Multimorbidity: what do we know? What should we do? J Comorbidity. 2016;6(1):4–11.

Perry RG, Mitchell JA, Hawkins J, Johnson-Lawrence V. The Role of Age and Multimorbidity in Shaping Older African American Men’s Experiences with Patient–Provider Communication. Geriatrics, 2018;3(4):74

Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel JM, Sundararajan V. Updating and Validating the Charlson Comorbidity Index and Score for Risk Adjustment in Hospital Discharge Abstracts Using Data From 6 Countries. Am J Epidemiol. 2011;173:676–682.

Ramond-Roquin A, Fortin M. Editorial Towards increased visibility of multimorbidity research. Journal of Comorbidity. 2016;6(2):42–45.

Rocca WA, Boyd CM, Grossardt BR, Bobo WV, Finney Rutten LJ, Roger VL, Ebbert JO, Therneau TM, Yawn BP, St Sauver JL. Prevalence of multimorbidity in a geographically defined American population: patterns by age, sex, and race/ethnicity. Mayo Clin Proc. 2014;89(10):1336–49. doi: 10.1016/j.mayocp.2014.07.010.

Roffman CE, Buchanan J, Garry T, Allison GT. Charlson Comorbidities Index. Journal of Physiotherapy. 2016;62:171.

Sachdev M, Sun JL, Tsiatis AA, Nelson CL, Mark DB, Jollis JG. The prognostic importance of comorbidity for mortality in patients with stable coronary artery disease. Journal of the American College of Cardiology. 2004;43(4):576–582.

Salisbury C. Multimorbidity: redesigning health care for people who use it. Lancet. 2012;380(9836):7–9.

Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ. 2012;345.

Smith SM, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews. 2016, Issue 3. No.CD006560. doi: 10.1002/14651858.CD006560.pub3.

Spitzer WO. The teacher’s teacher: a personal tribute to Alvan R. Feinstein. J Epidemiol Community Health. 2002;56:328–329.

St Sauver JL, Boyd CM, Grossardt BR, Bobo WV, Rutten LJF, Roger VL, Ebbert JO, Therneau TM, Yawn BP, Rocca WA. Risk of developing multimorbidity across all ages in an historical cohort study: differences by sex and ethnicity. BMJ Open., 2015;5(2):e006413. doi: 10.1136/bmjopen-2014-006413

Tauseef A, Fareed W, Bugti A, Naim MH, Lashari MN. Frequency of comorbidities and risk factors among ischaemic heart disease patients in Karachi - perspective from three tertiary care hospitals. J Pak Med Assoc., 2015;65(2): 235–8.

Tušek-Bunc K, Petek D. Comorbidities and characteristics of coronary heart disease patients: their impact on health-related quality of life. Health and Quality of Life Outcomes. 2016;14:159

Verheugt FW. The GRACE registry: how real-life evidence contributes to acute coronary syndrome guidelines. European Heart Journal, 2015; 17:D29–D31.

Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith SM. Managing patients with multimorbidity in primary care. Br Med J. 2015;350:h176.

Xu X, Mishra GD, Jones M. Evidence on multimorbidity from definition to intervention: An overview of systematic reviews. Ageing Res Rev. 2017;37:53–68. doi: 10.1016/j.arr.2017.05.003.

Zemedikun DT, Gray LJ, Khunti K, Davies M-J, Dhalwani NN. Patterns of multimorbidity in middle-aged and older adults: an analysis of the UK Biobank data. Mayo Clin Proc., 2018;93(7):857–866.

Zulman DM, Asch SM, Martins SB, Kerr EA, Hoffman BB, Goldstein MK. Quality of care for patients with multiple chronic conditions: the role of comorbidity interrelatedness. J Gen Int Med. 2014;29(3):529–37.