{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,25]],"date-time":"2026-10-25T00:55:25Z","timestamp":1792889725143,"version":"4.5.0"},"reference-count":140,"publisher":"BMJ","issue":"5","license":[{"start":{"date-parts":[[2021,5,5]],"date-time":"2021-05-05T00:00:00Z","timestamp":1620172800000},"content-version":"unspecified","delay-in-days":4,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Singapore Ministry of Health's National Medical Research Council under the Centre Grant Programme","award":["NMRC\/CG\/C019\/2017"],"award-info":[{"award-number":["NMRC\/CG\/C019\/2017"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2021,4,19]]},"published-print":{"date-parts":[[2021,5]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>There are multiple instruments for measuring multimorbidity. The main objective of this systematic review was to provide a list of instruments that are suitable for use in studies aiming to measure the association of a specific outcome with different levels of multimorbidity as the main independent variable in community-dwelling individuals. The secondary objective was to provide details of the requirements, strengths and limitations of these instruments, and the chosen outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      We conducted the review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO registration number: CRD42018105297). We searched MEDLINE, Embase and CINAHL electronic databases published in English and manually searched the\n                      <jats:italic>Journal of Comorbidity<\/jats:italic>\n                      between 1 January 2010 and 23 October 2020 inclusive. Studies also had to select adult patients from primary care or general population and had at least one specified outcome variable. Two authors screened the titles, abstracts and full texts independently. Disagreements were resolved with a third author. The modified Newcastle-Ottawa Scale was used for quality assessment.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Ninety-six studies were identified, with 69 of them rated to have a low risk of bias. In total, 33 unique instruments were described. Disease Count and weighted indices like Charlson Comorbidity Index were commonly used. Other approaches included pharmaceutical-based instruments. Disease Count was the common instrument used for measuring all three essential core outcomes of multimorbidity research: mortality, mental health and quality of life. There was a rise in the development of novel weighted indices by using prognostic models. The data obtained for measuring multimorbidity were from sources including medical records, patient self-reports and large administrative databases.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>We listed the details of 33 instruments for measuring the level of multimorbidity as a resource for investigators interested in the measurement of multimorbidity for its association with or prediction of a specific outcome.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2020-041219","type":"journal-article","created":{"date-parts":[[2021,5,5]],"date-time":"2021-05-05T13:55:47Z","timestamp":1620222947000},"page":"e041219","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":47,"title":["Systematic review on the instruments used for measuring the association of the level of multimorbidity and clinically important outcomes"],"prefix":"10.1136","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4963-535X","authenticated-orcid":false,"given":"Eng Sing","family":"Lee","sequence":"first","affiliation":[{"name":"Clinical Research Unit, National Healthcare Group Polyclinics, Singapore"},{"name":"Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hui Li","family":"Koh","sequence":"additional","affiliation":[{"name":"Clinical Research Unit, National Healthcare Group Polyclinics, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elaine Qiao-Ying","family":"Ho","sequence":"additional","affiliation":[{"name":"Saw Swee Hock School of Public Health, National University of Singapore, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sok Huang","family":"Teo","sequence":"additional","affiliation":[{"name":"Clinical Research Unit, National Healthcare Group Polyclinics, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fang Yan","family":"Wong","sequence":"additional","affiliation":[{"name":"Clinical Research Unit, National Healthcare Group Polyclinics, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bridget L","family":"Ryan","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada"},{"name":"Centre for Studies in Family Medicine, Department of Family Medicine, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"Fortin","sequence":"additional","affiliation":[{"name":"Department of Family Medicine and Emergency Medicine, Universit\u00e9 de Sherbrooke, Sherbrooke, Quebec, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Moira","family":"Stewart","sequence":"additional","affiliation":[{"name":"Centre for Studies in Family Medicine, Department of Family Medicine, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2021,5,5]]},"reference":[{"key":"2025121600492322000_11.5.e041219.1","unstructured":"WHO . The World Health Report 2008. Primary Care - Now more than ever, 2008."},{"key":"2025121600492322000_11.5.e041219.2","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.d4163","article-title":"How should we define health?","volume":"343","author":"Huber","year":"2011","journal-title":"BMJ"},{"key":"2025121600492322000_11.5.e041219.3","doi-asserted-by":"crossref","DOI":"10.1186\/s12875-015-0345-3","article-title":"Living with complexity; marshalling resources: a systematic review and qualitative meta-synthesis of lived experience of mental and physical multimorbidity","volume":"16","author":"Coventry","year":"2015","journal-title":"BMC Fam Pract"},{"key":"2025121600492322000_11.5.e041219.4","first-page":"1123","article-title":"Challenges of self-management when living with multiple chronic conditions: systematic review of the qualitative literature","volume":"60","author":"Liddy","year":"2014","journal-title":"Can Fam Physician"},{"key":"2025121600492322000_11.5.e041219.5","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0025987"},{"key":"2025121600492322000_11.5.e041219.6","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjmed.2003.09.031"},{"key":"2025121600492322000_11.5.e041219.7","doi-asserted-by":"publisher","DOI":"10.1370\/afm.1337"},{"key":"2025121600492322000_11.5.e041219.8","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2012.02.017"},{"key":"2025121600492322000_11.5.e041219.9","doi-asserted-by":"crossref","unstructured":"Sarfati D . How Do We Measure Comorbidity? In: Koczwara B , ed. Cancer and Chronic Conditions - Addressing the problem of multimorbidity in cancer patients and survivors. Springer, 2016: 35\u201370.","DOI":"10.1007\/978-981-10-1844-2_2"},{"key":"2025121600492322000_11.5.e041219.10","doi-asserted-by":"publisher","DOI":"10.1370\/afm.2178"},{"key":"2025121600492322000_11.5.e041219.11","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1002148"},{"key":"2025121600492322000_11.5.e041219.12","doi-asserted-by":"publisher","DOI":"10.1370\/afm.1363"},{"key":"2025121600492322000_11.5.e041219.13","unstructured":"Lee ES , EQ H , Koh HL . A systematic review on the instruments used for measuring the severity of multimorbidity, 2018. Available: https:\/\/www.crd.york.ac.uk\/prospero\/display_record.php?RecordID=105297"},{"key":"2025121600492322000_11.5.e041219.14","doi-asserted-by":"publisher","DOI":"10.1016\/S0895-4356(97)00306-5"},{"key":"2025121600492322000_11.5.e041219.15","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0136065","article-title":"Asthma and COPD overlap syndrome (ACOs): a systematic review and meta analysis","volume":"10","author":"Alshabanat","year":"2015","journal-title":"PLoS One"},{"key":"2025121600492322000_11.5.e041219.16","unstructured":"Wells GA , Shhea B , O'Connell D . The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available: http:\/\/www.ohri.ca\/programs\/clinical_epidemiology\/oxford.asp [Accessed 6 Apr 2018]."},{"key":"2025121600492322000_11.5.e041219.17","doi-asserted-by":"crossref","first-page":"39","DOI":"10.3109\/13814788.2014.914167","article-title":"The relationship of multimorbidity with disability and frailty in the oldest patients: a cross-sectional analysis of three measures of multimorbidity in the BELFRAIL cohort","volume":"21","author":"Boeckxstaens","year":"2015","journal-title":"Eur J Gen Pract"},{"key":"2025121600492322000_11.5.e041219.18","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2014.08.010"},{"key":"2025121600492322000_11.5.e041219.19","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1177\/0898264316641082","article-title":"Mood disorders in middle-aged and older veterans with multimorbidity","volume":"29","author":"DiNapoli","year":"2017","journal-title":"J Aging Health"},{"key":"2025121600492322000_11.5.e041219.20","doi-asserted-by":"publisher","DOI":"10.1016\/0021-9681(87)90171-8"},{"key":"2025121600492322000_11.5.e041219.21","first-page":"725","article-title":"Risk-Stratification methods for identifying patients for care coordination","volume":"19","author":"Haas","year":"2013","journal-title":"Am J Manag Care"},{"key":"2025121600492322000_11.5.e041219.22","doi-asserted-by":"publisher","DOI":"10.1186\/s12877-015-0001-8"},{"key":"2025121600492322000_11.5.e041219.23","first-page":"309","article-title":"Persistent high utilization in a privately insured population","volume":"21","author":"Hwang","year":"2015","journal-title":"Am J Manag Care"},{"key":"2025121600492322000_11.5.e041219.24","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1007\/s00420-015-1104-4","article-title":"Measuring multimorbidity in a working population: the effect on incident sickness absence","volume":"89","author":"Ubalde-Lopez","year":"2016","journal-title":"Int Arch Occup Environ Health"},{"key":"2025121600492322000_11.5.e041219.25","unstructured":"The Johns Hopkins ACG\u00ae system excerpt from version 11.0 technical reference guide 2014. Available: https:\/\/www.healthpartners.com\/ucm\/groups\/public\/@hp\/@public\/documents\/documents\/cntrb_035024.pdf [Accessed 10 Sep 2019]."},{"key":"2025121600492322000_11.5.e041219.26","doi-asserted-by":"publisher","DOI":"10.1097\/01.mlr.0000102367.93252.70"},{"key":"2025121600492322000_11.5.e041219.27","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0096142","article-title":"Multimorbidity and quality of preventive care in Swiss university primary care cohorts","volume":"9","author":"Streit","year":"2014","journal-title":"PLoS One"},{"key":"2025121600492322000_11.5.e041219.28","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1093\/aje\/kwx198","article-title":"Multimorbidity, mortality, and long-term physical functioning in 3 prospective cohorts of community-dwelling adults","volume":"187","author":"Wei","year":"2018","journal-title":"Am J Epidemiol"},{"key":"2025121600492322000_11.5.e041219.29","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1080\/02813430310004939","article-title":"The first general practitioner hospital in the Netherlands: towards a new form of integrated care?","volume":"22","author":"Moll van Charante","year":"2004","journal-title":"Scand J Prim Health Care"},{"key":"2025121600492322000_11.5.e041219.30","doi-asserted-by":"publisher","DOI":"10.1093\/epirev\/mxs009"},{"key":"2025121600492322000_11.5.e041219.31","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.b375"},{"key":"2025121600492322000_11.5.e041219.32","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1016\/j.ejim.2015.02.010","article-title":"Multimorbidity in risk stratification tools to predict negative outcomes in adult population","volume":"26","author":"Alonso-Mor\u00e1n","year":"2015","journal-title":"Eur J Intern Med"},{"key":"2025121600492322000_11.5.e041219.33","doi-asserted-by":"publisher","DOI":"10.1016\/0895-4356(92)90016-G"},{"key":"2025121600492322000_11.5.e041219.34","doi-asserted-by":"publisher","DOI":"10.1097\/00005650-200301000-00011"},{"key":"2025121600492322000_11.5.e041219.35","doi-asserted-by":"publisher","DOI":"10.1097\/00005650-200306000-00009"},{"key":"2025121600492322000_11.5.e041219.36","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1093\/gerona\/62.3.281","article-title":"Methodology, design, and analytic techniques to address measurement of comorbid disease","volume":"62","author":"Lash","year":"2007","journal-title":"J Gerontol A Biol Sci Med Sci"},{"key":"2025121600492322000_11.5.e041219.37","doi-asserted-by":"publisher","DOI":"10.9778\/cmajo.20170029"},{"key":"2025121600492322000_11.5.e041219.38","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2005.02.025"},{"key":"2025121600492322000_11.5.e041219.39","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0009810"},{"key":"2025121600492322000_11.5.e041219.40","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2014.09.010"},{"key":"2025121600492322000_11.5.e041219.41","doi-asserted-by":"publisher","DOI":"10.1007\/s11136-012-0214-7"},{"key":"2025121600492322000_11.5.e041219.42","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-015-0698-2","article-title":"Multimorbidity, health care utilization and costs in an elderly community-dwelling population: a claims data based observational study","volume":"15","author":"B\u00e4hler","year":"2015","journal-title":"BMC Health Serv Res"},{"key":"2025121600492322000_11.5.e041219.43","doi-asserted-by":"crossref","DOI":"10.5888\/pcd10.120282","article-title":"Multiple chronic medical conditions and health-related quality of life in older adults, 2004\u20132006","volume":"10","author":"Barile","year":"2013","journal-title":"Prev Chronic Dis"},{"key":"2025121600492322000_11.5.e041219.44","doi-asserted-by":"publisher","DOI":"10.1097\/JAC.0b013e31826746f5"},{"key":"2025121600492322000_11.5.e041219.45","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(12)60240-2"},{"key":"2025121600492322000_11.5.e041219.46","first-page":"829","article-title":"Prediction of critical illness in elderly outpatients using elder risk assessment: a population-based study","volume":"11","author":"Biehl","year":"2016","journal-title":"Clin Interv Aging"},{"key":"2025121600492322000_11.5.e041219.47","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhealeco.2014.02.005"},{"key":"2025121600492322000_11.5.e041219.48","doi-asserted-by":"publisher","DOI":"10.1093\/fampra\/cms060"},{"key":"2025121600492322000_11.5.e041219.49","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1016\/j.healthpol.2019.02.002","article-title":"Predicting healthcare expenditure by multimorbidity groups","volume":"123","author":"Caballer-Tarazona","year":"2019","journal-title":"Health Policy"},{"key":"2025121600492322000_11.5.e041219.50","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2012.10.012"},{"key":"2025121600492322000_11.5.e041219.51","doi-asserted-by":"crossref","first-page":"909","DOI":"10.1097\/MLR.0000000000000428","article-title":"Mortality risk prediction: can comorbidity indices be improved with psychosocial data?","volume":"53","author":"Chapman","year":"2015","journal-title":"Med Care"},{"key":"2025121600492322000_11.5.e041219.52","article-title":"Health-Related quality of life among adults with multiple chronic conditions in the United States, behavioral risk factor surveillance system, 2007","volume":"8","author":"Chen","year":"2011","journal-title":"Prev Chronic Dis"},{"key":"2025121600492322000_11.5.e041219.53","doi-asserted-by":"crossref","first-page":"1447","DOI":"10.1111\/ggi.13510","article-title":"Multimorbidity among middle-aged and older persons in urban China: prevalence, characteristics and health service utilization","volume":"18","author":"Chen","year":"2018","journal-title":"Geriatr Gerontol Int"},{"key":"2025121600492322000_11.5.e041219.54","unstructured":"Chu T , Lau P , Cheng RSY . A study on the prevalence of multi - morbidities of diseases and utilisation of public healthcare services in the New Territories West area of Hong Kong. The Hong Kong Practitioner 2018;40."},{"key":"2025121600492322000_11.5.e041219.55","doi-asserted-by":"crossref","first-page":"1443","DOI":"10.1007\/s40520-020-01500-8","article-title":"Does self-report of multimorbidity in later life predict impaired physical functioning, and might this be useful in clinical practice?","volume":"32","author":"Clynes","year":"2020","journal-title":"Aging Clin Exp Res"},{"key":"2025121600492322000_11.5.e041219.56","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-10-338"},{"key":"2025121600492322000_11.5.e041219.57","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0165507","article-title":"The use of a Bayesian hierarchy to develop and validate a co-morbidity score to predict mortality for linked primary and secondary care data from the NHS in England","volume":"11","author":"Crooks","year":"2016","journal-title":"PLoS One"},{"key":"2025121600492322000_11.5.e041219.58","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2015-007974"},{"key":"2025121600492322000_11.5.e041219.59","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1089\/rej.2013.1422","article-title":"Utility of geriatric assessment to predict mortality in the oldest old: the Octabaix study 3-year follow-up","volume":"16","author":"Formiga","year":"2013","journal-title":"Rejuvenation Res"},{"key":"2025121600492322000_11.5.e041219.60","doi-asserted-by":"publisher","DOI":"10.1093\/ageing\/afq127"},{"key":"2025121600492322000_11.5.e041219.61","doi-asserted-by":"publisher","DOI":"10.1089\/rej.2010.1131"},{"key":"2025121600492322000_11.5.e041219.62","doi-asserted-by":"crossref","first-page":"437","DOI":"10.2147\/CIA.S101447","article-title":"Evidence of functional declining and global comorbidity measured at baseline proved to be the strongest predictors for long-term death in elderly community residents aged 85 years: a 5-year follow-up evaluation, the OCTABAIX study","volume":"11","author":"Formiga","year":"2016","journal-title":"Clin Interv Aging"},{"key":"2025121600492322000_11.5.e041219.63","doi-asserted-by":"crossref","DOI":"10.1097\/MD.0000000000004973","article-title":"Predicting mortality from change-over-time in the Charlson comorbidity index: a retrospective cohort study in a data-intensive UK health system","volume":"95","author":"Fraccaro","year":"2016","journal-title":"Medicine"},{"key":"2025121600492322000_11.5.e041219.64","doi-asserted-by":"crossref","first-page":"380","DOI":"10.1093\/geronb\/gbr032","article-title":"Somatic multimorbidity and self-rated health in the older population","volume":"66","author":"Galenkamp","year":"2011","journal-title":"J Gerontol B Psychol Sci Soc Sci"},{"key":"2025121600492322000_11.5.e041219.65","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0111498","article-title":"Impact of multimorbidity on disability and quality of life in the Spanish older population","volume":"9","author":"Garin","year":"2014","journal-title":"PLoS One"},{"key":"2025121600492322000_11.5.e041219.66","doi-asserted-by":"publisher","DOI":"10.1093\/fampra\/cmr013"},{"key":"2025121600492322000_11.5.e041219.67","doi-asserted-by":"publisher","DOI":"10.1007\/s00127-010-0330-z"},{"key":"2025121600492322000_11.5.e041219.68","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2009.06.013"},{"key":"2025121600492322000_11.5.e041219.69","first-page":"45","article-title":"Effect of comorbidities and medications on frequency of primary care visits among older patients","volume":"63","author":"Hu","year":"2017","journal-title":"Can Fam Physician"},{"key":"2025121600492322000_11.5.e041219.70","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1080\/20786204.2014.10844582","article-title":"A snapshot of noncommunicable disease profiles and their prescription costs at ten primary healthcare facilities in the in the Western half of the Cape town Metropole","volume":"56","author":"Isaacs","year":"2014","journal-title":"South African Family Practice"},{"key":"2025121600492322000_11.5.e041219.71","first-page":"e519","article-title":"Targeting a high-risk group for fall prevention: strategies for health plans","volume":"21","author":"Jennings","year":"2015","journal-title":"Am J Manag Care"},{"key":"2025121600492322000_11.5.e041219.72","doi-asserted-by":"crossref","first-page":"740","DOI":"10.1097\/MLR.0000000000000943","article-title":"Quality-Adjusted life years (QALY) for 15 chronic conditions and combinations of conditions among US adults aged 65 and older","volume":"56","author":"Jia","year":"2018","journal-title":"Med Care"},{"key":"2025121600492322000_11.5.e041219.73","doi-asserted-by":"publisher","DOI":"10.1007\/s11136-016-1226-5"},{"key":"2025121600492322000_11.5.e041219.74","doi-asserted-by":"publisher","DOI":"10.5888\/pcd13.160174"},{"key":"2025121600492322000_11.5.e041219.75","doi-asserted-by":"publisher","DOI":"10.1016\/j.genm.2012.08.001"},{"key":"2025121600492322000_11.5.e041219.76","doi-asserted-by":"crossref","first-page":"438","DOI":"10.1111\/j.1447-0594.2011.00703.x","article-title":"Association of polypharmacy with fall risk among geriatric outpatients","volume":"11","author":"Kojima","year":"2011","journal-title":"Geriatr Gerontol Int"},{"key":"2025121600492322000_11.5.e041219.77","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1007\/s10198-013-0499-7","article-title":"Association between fee-for-service expenditures and morbidity burden in primary care","volume":"15","author":"Kristensen","year":"2014","journal-title":"Eur J Health Econ"},{"key":"2025121600492322000_11.5.e041219.78","doi-asserted-by":"crossref","first-page":"884","DOI":"10.1016\/j.jval.2015.05.004","article-title":"Development and validation of a score for adjusting health care costs in general practice","volume":"18","author":"Lapi","year":"2015","journal-title":"Value Health"},{"key":"2025121600492322000_11.5.e041219.79","doi-asserted-by":"publisher","DOI":"10.1186\/1475-9276-12-67"},{"key":"2025121600492322000_11.5.e041219.80","doi-asserted-by":"publisher","DOI":"10.1097\/MLR.0b013e3182353ceb"},{"key":"2025121600492322000_11.5.e041219.81","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1186\/s12889-016-3335-z","article-title":"Patterns of multimorbidity and their association with health outcomes within Yorkshire, England: baseline results from the Yorkshire health study","volume":"16","author":"Li","year":"2016","journal-title":"BMC Public Health"},{"key":"2025121600492322000_11.5.e041219.82","doi-asserted-by":"crossref","DOI":"10.1007\/s11357-016-9874-5","article-title":"Multimorbidity, cognitive function, and physical activity","volume":"38","author":"Loprinzi","year":"2016","journal-title":"Age"},{"key":"2025121600492322000_11.5.e041219.83","doi-asserted-by":"publisher","DOI":"10.26633\/RPSP.2019.8"},{"key":"2025121600492322000_11.5.e041219.84","doi-asserted-by":"crossref","first-page":"11","DOI":"10.15256\/joc.2011.1.3","article-title":"Prevalence of disability according to multimorbidity and disease clustering: a population-based study","volume":"1","author":"Marengoni","year":"2011","journal-title":"J Comorb"},{"key":"2025121600492322000_11.5.e041219.85","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2013-002571"},{"key":"2025121600492322000_11.5.e041219.86","doi-asserted-by":"crossref","first-page":"e63","DOI":"10.1016\/j.archger.2009.05.012","article-title":"Developing a self-reported comorbidity index to predict mortality of community-dwelling older adults","volume":"50","author":"Md Yusof","year":"2010","journal-title":"Arch Gerontol Geriatr"},{"key":"2025121600492322000_11.5.e041219.87","doi-asserted-by":"crossref","DOI":"10.1186\/s12955-018-1063-z","article-title":"Measurement of health-related quality by multimorbidity groups in primary health care","volume":"17","author":"Mill\u00e1-Perseguer","year":"2019","journal-title":"Health Qual Life Outcomes"},{"key":"2025121600492322000_11.5.e041219.88","doi-asserted-by":"crossref","DOI":"10.1186\/s12875-020-01104-1","article-title":"Multimorbidity as a predictor of health service utilization in primary care: a registry-based study of the Catalan population","volume":"21","author":"Monterde","year":"2020","journal-title":"BMC Fam Pract"},{"key":"2025121600492322000_11.5.e041219.89","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-12-452"},{"key":"2025121600492322000_11.5.e041219.90","doi-asserted-by":"publisher","DOI":"10.1007\/s11136-014-0820-7"},{"key":"2025121600492322000_11.5.e041219.91","first-page":"118","article-title":"Effect of multiple chronic conditions among working-age adults","volume":"17","author":"Naessens","year":"2011","journal-title":"Am J Manag Care"},{"key":"2025121600492322000_11.5.e041219.92","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-0447.2010.01668.x"},{"key":"2025121600492322000_11.5.e041219.93","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1377\/hlthaff.2018.05273","article-title":"Multimorbidity and health outcomes in older adults in ten European health systems, 2006\u201315","volume":"38","author":"Palladino","year":"2019","journal-title":"Health Aff"},{"key":"2025121600492322000_11.5.e041219.94","doi-asserted-by":"publisher","DOI":"10.1186\/s12955-019-1180-3"},{"key":"2025121600492322000_11.5.e041219.95","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.121349"},{"key":"2025121600492322000_11.5.e041219.96","doi-asserted-by":"publisher","DOI":"10.1111\/bcp.12292"},{"key":"2025121600492322000_11.5.e041219.97","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.190757"},{"key":"2025121600492322000_11.5.e041219.98","doi-asserted-by":"crossref","first-page":"103","DOI":"10.2147\/PROM.S148358","article-title":"Quality of life and burden of morbidity in primary care users with multimorbidity","volume":"9","author":"Peters","year":"2018","journal-title":"Patient Relat Outcome Meas"},{"key":"2025121600492322000_11.5.e041219.99","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-11-146"},{"key":"2025121600492322000_11.5.e041219.100","doi-asserted-by":"crossref","first-page":"99","DOI":"10.3109\/02813432.2014.929819","article-title":"Importance of healthcare utilization and multimorbidity level in choosing a primary care provider in Sweden","volume":"32","author":"Ranstad","year":"2014","journal-title":"Scand J Prim Health Care"},{"key":"2025121600492322000_11.5.e041219.101","doi-asserted-by":"crossref","first-page":"880","DOI":"10.1016\/j.jpainsymman.2019.02.011","article-title":"Symptom burden and palliative care needs among high-risk veterans with multimorbidity","volume":"57","author":"Reinke","year":"2019","journal-title":"J Pain Symptom Manage"},{"key":"2025121600492322000_11.5.e041219.102","doi-asserted-by":"crossref","first-page":"325","DOI":"10.2147\/CIA.S156116","article-title":"Effects of frailty and chronic diseases on quality of life in Dutch community-dwelling older adults: a cross-sectional study","volume":"13","author":"Renne","year":"2018","journal-title":"Clin Interv Aging"},{"key":"2025121600492322000_11.5.e041219.103","doi-asserted-by":"crossref","first-page":"1751","DOI":"10.1007\/s00198-014-2682-9","article-title":"The impact of common co-morbidities (as measured using the Charlson index) on hip fracture risk in elderly men: a population-based cohort study","volume":"25","author":"Reyes","year":"2014","journal-title":"Osteoporos Int"},{"key":"2025121600492322000_11.5.e041219.104","doi-asserted-by":"crossref","DOI":"10.1186\/s12955-015-0285-6","article-title":"Quantifying the importance of disease burden on perceived general health and depressive symptoms in patients within the Mayo clinic Biobank","volume":"13","author":"Ryu","year":"2015","journal-title":"Health Qual Life Outcomes"},{"key":"2025121600492322000_11.5.e041219.105","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp11X548929"},{"key":"2025121600492322000_11.5.e041219.106","doi-asserted-by":"publisher","DOI":"10.1093\/eurpub\/ckt019"},{"key":"2025121600492322000_11.5.e041219.107","doi-asserted-by":"crossref","DOI":"10.1186\/1471-2458-11-609","article-title":"Assessing socioeconomic health care utilization inequity in Israel: impact of alternative approaches to morbidity adjustment","volume":"11","author":"Shadmi","year":"2011","journal-title":"BMC Public Health"},{"key":"2025121600492322000_11.5.e041219.108","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2318-14-22"},{"key":"2025121600492322000_11.5.e041219.109","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2017.08.005"},{"key":"2025121600492322000_11.5.e041219.110","first-page":"e272","article-title":"Multimorbidity, disability, and mortality in community-dwelling older adults","volume":"60","author":"St John","year":"2014","journal-title":"Can Fam Physician"},{"key":"2025121600492322000_11.5.e041219.111","first-page":"e56","article-title":"Multimorbidity predicts functional decline in community-dwelling older adults: prospective cohort study","volume":"65","author":"St John","year":"2019","journal-title":"Can Fam Physician"},{"key":"2025121600492322000_11.5.e041219.112","doi-asserted-by":"publisher","DOI":"10.2165\/11586840-000000000-00000"},{"key":"2025121600492322000_11.5.e041219.113","doi-asserted-by":"publisher","DOI":"10.1016\/j.archger.2011.02.012"},{"key":"2025121600492322000_11.5.e041219.114","first-page":"475","article-title":"Enhanced risk prediction model for emergency department use and hospitalizations in patients in a primary care medical home","volume":"22","author":"Takahashi","year":"2016","journal-title":"Am J Manag Care"},{"key":"2025121600492322000_11.5.e041219.115","doi-asserted-by":"crossref","first-page":"2579","DOI":"10.1007\/s11136-016-1282-x","article-title":"Predictors of health-related quality of life in people with a complex chronic disease including multimorbidity: a longitudinal cohort study","volume":"25","author":"Tyack","year":"2016","journal-title":"Qual Life Res"},{"key":"2025121600492322000_11.5.e041219.116","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2318-11-54"},{"key":"2025121600492322000_11.5.e041219.117","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2296-15-61"},{"key":"2025121600492322000_11.5.e041219.118","doi-asserted-by":"crossref","first-page":"117","DOI":"10.3109\/13814788.2012.755511","article-title":"Multimorbidity in older women: the negative impact of specific combinations of chronic conditions on self-rated health","volume":"19","author":"Vos","year":"2013","journal-title":"Eur J Gen Pract"},{"key":"2025121600492322000_11.5.e041219.119","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2016-012336"},{"key":"2025121600492322000_11.5.e041219.120","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2016-013089"},{"key":"2025121600492322000_11.5.e041219.121","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1093\/gerona\/glx114","article-title":"Multimorbidity and physical and cognitive function: performance of a new Multimorbidity-Weighted index","volume":"73","author":"Wei","year":"2018","journal-title":"J Gerontol A Biol Sci Med Sci"},{"key":"2025121600492322000_11.5.e041219.122","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1093\/gerona\/gly038","article-title":"Physical functioning decline and mortality in older adults with multimorbidity: joint modeling of longitudinal and survival data","volume":"74","author":"Wei","year":"2019","journal-title":"J Gerontol A Biol Sci Med Sci"},{"key":"2025121600492322000_11.5.e041219.123","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1111\/jgs.15678","article-title":"Multimorbidity and mental health-related quality of life and risk of completed suicide","volume":"67","author":"Wei","year":"2019","journal-title":"J Am Geriatr Soc"},{"key":"2025121600492322000_11.5.e041219.124","doi-asserted-by":"publisher","DOI":"10.1093\/gerona\/glz147"},{"key":"2025121600492322000_11.5.e041219.125","doi-asserted-by":"crossref","first-page":"999","DOI":"10.1111\/jgs.16310","article-title":"Multimorbidity in Medicare beneficiaries: performance of an ICD-Coded Multimorbidity-Weighted index","volume":"68","author":"Wei","year":"2020","journal-title":"J Am Geriatr Soc"},{"key":"2025121600492322000_11.5.e041219.126","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0018952"},{"key":"2025121600492322000_11.5.e041219.127","doi-asserted-by":"publisher","DOI":"10.1111\/j.1532-5415.1968.tb02103.x"},{"key":"2025121600492322000_11.5.e041219.128","doi-asserted-by":"publisher","DOI":"10.1016\/0165-1781(92)90005-N"},{"key":"2025121600492322000_11.5.e041219.129","doi-asserted-by":"publisher","DOI":"10.1097\/MLR.0b013e318215d7dd"},{"key":"2025121600492322000_11.5.e041219.130","doi-asserted-by":"publisher","DOI":"10.1186\/1477-7525-3-51"},{"key":"2025121600492322000_11.5.e041219.131","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2008.05.002"},{"key":"2025121600492322000_11.5.e041219.132","doi-asserted-by":"publisher","DOI":"10.1097\/00005650-199801000-00004"},{"key":"2025121600492322000_11.5.e041219.133","first-page":"119","article-title":"Risk adjustment of Medicare capitation payments using the CMS-HCC model","volume":"25","author":"Pope","year":"2004","journal-title":"Health Care Financ Rev"},{"key":"2025121600492322000_11.5.e041219.134","doi-asserted-by":"publisher","DOI":"10.1093\/geronj\/36.4.428"},{"key":"2025121600492322000_11.5.e041219.135","doi-asserted-by":"publisher","DOI":"10.1097\/00005650-200202000-00006"},{"key":"2025121600492322000_11.5.e041219.136","doi-asserted-by":"publisher","DOI":"10.1093\/aje\/kwv456"},{"key":"2025121600492322000_11.5.e041219.137","first-page":"53","article-title":"Ambulatory care groups: a categorization of diagnoses for research and management","volume":"26","author":"Starfield","year":"1991","journal-title":"Health Serv Res"},{"key":"2025121600492322000_11.5.e041219.138","doi-asserted-by":"publisher","DOI":"10.1097\/00005650-199105000-00006"},{"key":"2025121600492322000_11.5.e041219.139","doi-asserted-by":"publisher","DOI":"10.1016\/J.APRIM.2016.06.003"},{"key":"2025121600492322000_11.5.e041219.140","doi-asserted-by":"publisher","DOI":"10.1111\/j.1532-5415.1993.tb06175.x"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2020-041219","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T08:49:36Z","timestamp":1765874976000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2020-041219"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,5]]},"references-count":140,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2021,5,5]]},"published-print":{"date-parts":[[2021,5]]}},"alternative-id":["10.1136\/bmjopen-2020-041219"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2020-041219","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,5]]}}}