{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T11:07:01Z","timestamp":1789556821694,"version":"build-2803163510"},"reference-count":36,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T00:00:00Z","timestamp":1787702400000},"content-version":"unspecified","delay-in-days":56,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Open Heart"],"accepted":{"date-parts":[[2026,8,20]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The expansion of universal health coverage (UHC) in many low- and middle-income countries (LMICs) has occurred alongside a growing burden of chronic disease and multimorbidity. Heart failure (HF) frequently coexists with multimorbidity, which is associated with worse hospitalisation outcomes. However, most evidence on multimorbidity and HF hospitalisation outcomes originates from older populations in high-income countries and nationally representative evidence from LMIC settings remains limited. We aimed to characterise multimorbidity burden among patients hospitalised with HF, evaluate associations with length of stay (LOS) and readmission and identify individual comorbidities associated with these outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a population-based retrospective cohort study using nationally representative, probability-weighted administrative claims from Badan Penyelenggara Jaminan Sosial Kesehatan, Indonesia\u2019s national health insurance programme (2019\u20132024). Adults (\u226518 years) hospitalised with HF as the primary diagnosis were included. 12 prespecified comorbidities were ascertained from all available claims. Multimorbidity was defined as the number of comorbidities beyond HF. Outcomes were LOS and 30-day and 90-day HF-specific readmissions, analysed using survey-weighted linear and logistic regression adjusted for age and sex.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 9018 patients contributing 12 461 HF episodes (mean age 59.8\u00b113.1 years; 51.4% male), multimorbidity was present in 72.4%. Each additional comorbidity was associated with longer LOS (\u03b2 0.13\u2009days; 95%\u2009CI 0.03 to 0.22), higher 30-day readmission odds (OR 1.22; 95%\u2009CI 1.07 to 1.38) and higher 90-day readmission odds (OR 1.27; 95%\u2009CI 1.14 to 1.42). Distinct comorbidity patterns were observed across outcomes: anaemia showed the strongest association with prolonged LOS, whereas ischaemic heart disease, chronic kidney disease, chronic obstructive pulmonary disease and valvular disease were associated with readmission.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Multimorbidity is highly prevalent among patients hospitalised with HF in Indonesia and is associated with adverse hospitalisation outcomes. Both multimorbidity burden and specific comorbidities were associated with these outcomes, suggesting a need for health systems that better account for multimorbidity.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/openhrt-2026-004340","type":"journal-article","created":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T10:45:11Z","timestamp":1787741111000},"page":"e004340","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Multimorbidity burden and hospitalisation outcomes in heart failure: a retrospective cohort study using Indonesian national health insurance claims data (2019\u20132024)"],"prefix":"10.1136","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-2256-4698","authenticated-orcid":false,"given":"Gita","family":"Yolanda","sequence":"first","affiliation":[{"name":"Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, DI Yogyakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-0502-8666","authenticated-orcid":false,"given":"Arditya","family":"Damarkusuma","sequence":"additional","affiliation":[{"name":"Department of Cardiology and Vascular Medicine Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Yogyakarta, DI Yogyakarta, Indonesia"},{"name":"Clinical Epidemiology and Biostatistics Unit (CEBU), Faculty of Medicine Public Health and Nursing, Gadjah Mada University, Yogyakarta, Jogja, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,26]]},"reference":[{"key":"2026091603502606000_13.2.e004340.1","unstructured":"Mahendradhata Y , Trisnantoro L , Listyadewi S , et al . The republic of Indonesia health system review. Asia pacific observatory on health systems and policies. New Delhi World Health Organization Regional Office for South-East Asia; 2017. Available: https:\/\/iris.who.int\/items\/6d65bc05-179f-4875-9a8c-60d5df4911a2"},{"key":"2026091603502606000_13.2.e004340.2","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2015-009810","article-title":"Multimorbidity prevalence and pattern in Indonesian adults: an exploratory study using national survey data","volume":"5","author":"Hussain","year":"2015","journal-title":"BMJ Open"},{"key":"2026091603502606000_13.2.e004340.3","doi-asserted-by":"crossref","first-page":"e1874","DOI":"10.1016\/S2214-109X(23)00408-4","article-title":"Multimorbidity in patients with acute heart failure across world regions and country income levels (REPORT-HF): a prospective, multicentre, global cohort study","volume":"11","author":"Gerhardt","year":"2023","journal-title":"Lancet Glob Health"},{"key":"2026091603502606000_13.2.e004340.4","doi-asserted-by":"crossref","first-page":"1469","DOI":"10.1111\/jgs.14206","article-title":"Multimorbidity in heart failure: Effect on outcomes","volume":"64","author":"Manemann","year":"2016","journal-title":"J Am Geriatr Soc"},{"key":"2026091603502606000_13.2.e004340.5","doi-asserted-by":"crossref","DOI":"10.3390\/jcm13133979","article-title":"Multimorbidity in incident heart failure: Characterisation and impact on 1-year outcomes","volume":"13","author":"Gracia Guti\u00e9rrez","year":"2024","journal-title":"J Clin Med"},{"key":"2026091603502606000_13.2.e004340.6","unstructured":"Kesehatan B . Laporan pengelolaan program tahun 2023 dan laporan keuangan tahun 2023 (auditan). Jakarta BPJS Kesehatan; 2024."},{"key":"2026091603502606000_13.2.e004340.7","unstructured":"Kesehatan B . Laporan pengelolaan program tahun 2024 dan laporan keuangan tahun 2024 (auditan). Jakarta BPJS Kesehatan; 2025."},{"key":"2026091603502606000_13.2.e004340.8","unstructured":"Kesehatan B . Laporan pengelolaan program tahun 2020 dan laporan keuangan tahun 2020 (auditan). Jakarta BPJS Kesehatan; 2021."},{"key":"2026091603502606000_13.2.e004340.9","unstructured":"Kesehatan B . Laporan pengelolaan program tahun 2022 dan laporan keuangan tahun 2022 (auditan). Jakarta BPJS Kesehatan; 2023."},{"key":"2026091603502606000_13.2.e004340.10","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-041870","article-title":"Impact of non-communicable disease multimorbidity on health service use, catastrophic health expenditure and productivity loss in Indonesia: a population-based panel data analysis study","volume":"11","author":"Marthias","year":"2021","journal-title":"BMJ Open"},{"key":"2026091603502606000_13.2.e004340.11","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-024-18301-7","article-title":"The impact of multimorbidity among adults with cardiovascular diseases on healthcare costs in Indonesia: a multilevel analysis","volume":"24","author":"Ramadani","year":"2024","journal-title":"BMC Public Health"},{"key":"2026091603502606000_13.2.e004340.12","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1001\/jamacardio.2019.5108","article-title":"Global differences in characteristics, precipitants, and initial management of patients presenting with acute heart failure","volume":"5","author":"Filippatos","year":"2020","journal-title":"JAMA Cardiol"},{"key":"2026091603502606000_13.2.e004340.13","doi-asserted-by":"publisher","DOI":"10.1002\/ejhf.57"},{"key":"2026091603502606000_13.2.e004340.14","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1002\/ehf2.12046","article-title":"Clinical characteristics and management of hospitalized and ambulatory patients with heart failure-results from ESC heart failure long-term registry-Egyptian cohort","volume":"2","author":"Hassanein","year":"2015","journal-title":"ESC Heart Fail"},{"key":"2026091603502606000_13.2.e004340.15","unstructured":"Kesehatan B . Buku data sampel BPJS Kesehatan 2015\u20132020 [BPJS Kesehatan sample data book 2015\u20132020]; Jakarta BPJS Kesehatan; 2021."},{"key":"2026091603502606000_13.2.e004340.16","unstructured":"World Health Organization . International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). Geneva: World Health Organization, 2019."},{"key":"2026091603502606000_13.2.e004340.17","doi-asserted-by":"crossref","first-page":"944","DOI":"10.3349\/ymj.2017.58.5.944","article-title":"Healthcare costs for acute hospitalized and chronic heart failure in South Korea: A multi-center retrospective cohort study","volume":"58","author":"Ku","year":"2017","journal-title":"Yonsei Med J"},{"key":"2026091603502606000_13.2.e004340.18","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1002\/pds.2313","article-title":"A systematic review of validated methods for identifying heart failure using administrative data","volume":"21 Suppl 1","author":"Saczynski","year":"2012","journal-title":"Pharmacoepidemiol Drug Saf"},{"key":"2026091603502606000_13.2.e004340.19","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2024-091115","article-title":"Correlation between economic status and severity of type 2 diabetes mellitus in Indonesia: analysis of claim data from the national health insurance scheme, 2018-2022","volume":"15","author":"Ahsan","year":"2025","journal-title":"BMJ Open"},{"key":"2026091603502606000_13.2.e004340.20","doi-asserted-by":"crossref","first-page":"517","DOI":"10.1007\/s41669-019-0127-2","article-title":"National Health Insurance Databases in Indonesia, Vietnam and the Philippines","volume":"3","author":"Ng","year":"2019","journal-title":"Pharmacoecon Open"},{"key":"2026091603502606000_13.2.e004340.21","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1093\/ehjqcco\/qcx015","article-title":"Recurrent events analysis for examination of hospitalizations in heart failure: insights from the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) trial","volume":"4","author":"Braga","year":"2018","journal-title":"Eur Heart J Qual Care Clin Outcomes"},{"key":"2026091603502606000_13.2.e004340.22","unstructured":"Republic of Indonesia . Undang-undang nomor 13 tahun 2011 tentang Penanganan Fakir Miskin [law no.13 of 2011 on the treatment of poor and vulnerable people]. Indonesia, 2011."},{"key":"2026091603502606000_13.2.e004340.23","doi-asserted-by":"publisher","DOI":"10.1177\/1460458216647089"},{"key":"2026091603502606000_13.2.e004340.24","doi-asserted-by":"crossref","first-page":"1","DOI":"10.18637\/jss.v009.i08","article-title":"Analysis of complex survey samples","volume":"9","author":"Lumley","year":"2004","journal-title":"J Stat Soft"},{"key":"2026091603502606000_13.2.e004340.25","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2021-051997","article-title":"Disparities in prevalence of heart failure according to age, multimorbidity level and socioeconomic status in southern Sweden: a cross-sectional study","volume":"12","author":"Scholten","year":"2022","journal-title":"BMJ Open"},{"key":"2026091603502606000_13.2.e004340.26","doi-asserted-by":"crossref","first-page":"1273","DOI":"10.1002\/ejhf.3676","article-title":"Heart failure and obesity: Translational approaches and therapeutic perspectives. A scientific statement of the heart failure association of the ESC","volume":"27","author":"Savarese","year":"2025","journal-title":"Eur J Heart Fail"},{"key":"2026091603502606000_13.2.e004340.27","doi-asserted-by":"crossref","DOI":"10.1097\/MD.0000000000016438","article-title":"Assessment of obesity prevalence and validity of obesity diagnoses coded in claims data for selected surgical populations: A retrospective, observational study","volume":"98","author":"Ammann","year":"2019","journal-title":"Medicine (Baltimore)"},{"key":"2026091603502606000_13.2.e004340.28","doi-asserted-by":"crossref","first-page":"1178222616685880","DOI":"10.1177\/1178222616685880","article-title":"Using electronic medical record to identify patients with dyslipidemia in primary care settings: International Classification of Disease Code matters from One region to a national database","volume":"9","author":"Oake","year":"2017","journal-title":"Biomed Inform Insights"},{"key":"2026091603502606000_13.2.e004340.29","doi-asserted-by":"crossref","DOI":"10.1161\/CIRCHEARTFAILURE.121.008335","article-title":"Trends in 30- and 90-day readmission rates for heart failure","volume":"14","author":"Khan","year":"2021","journal-title":"Circ Heart Fail"},{"key":"2026091603502606000_13.2.e004340.30","doi-asserted-by":"crossref","first-page":"444","DOI":"10.1001\/jamacardio.2019.0766","article-title":"Trends in readmissions and length of stay for patients hospitalized with heart failure in Canada and the United States","volume":"4","author":"Samsky","year":"2019","journal-title":"JAMA Cardiol"},{"key":"2026091603502606000_13.2.e004340.31","doi-asserted-by":"publisher","DOI":"10.1007\/s11897-023-00626-w"},{"key":"2026091603502606000_13.2.e004340.32","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1016\/j.ijcard.2016.07.264","article-title":"The association between in-hospital hemoglobin changes, cardiovascular events, and mortality in acute decompensated heart failure: Results from the ESCAPE trial","volume":"222","author":"Damluji","year":"2016","journal-title":"Int J Cardiol"},{"key":"2026091603502606000_13.2.e004340.33","doi-asserted-by":"crossref","DOI":"10.1136\/openhrt-2024-002851","article-title":"Impact of iron deficiency on congestion and postdischarge survival in patients recently hospitalised for decompensated heart failure: a multicentre, prospective, observational analysis of the FERIC-RO study","volume":"12","author":"Margineanu","year":"2025","journal-title":"Open Heart"},{"key":"2026091603502606000_13.2.e004340.34","doi-asserted-by":"crossref","first-page":"159","DOI":"10.36628\/ijhf.2023.0015","article-title":"Etiologies and predictors of 30-day readmission in heart failure: An updated analysis","volume":"5","author":"Jain","year":"2023","journal-title":"Int J Heart Fail"},{"key":"2026091603502606000_13.2.e004340.35","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0270809","article-title":"Length of hospital stay and associated factors among heart failure patients admitted to the University Hospital in Northwest Ethiopia","volume":"17","author":"Tigabe Tekle","year":"2022","journal-title":"PLoS ONE"},{"key":"2026091603502606000_13.2.e004340.36","doi-asserted-by":"crossref","DOI":"10.3390\/jcm11195922","article-title":"Risk predictors of 3-month and 1-year outcomes in heart failure patients with prior ischemic stroke","volume":"11","author":"Li","year":"2022","journal-title":"J Clin Med"}],"container-title":["Open Heart"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/openhrt-2026-004340","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T10:50:49Z","timestamp":1789555849000},"score":1,"resource":{"primary":{"URL":"https:\/\/openheart.bmj.com\/lookup\/doi\/10.1136\/openhrt-2026-004340"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7]]},"references-count":36,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,8,26]]},"published-print":{"date-parts":[[2026,7]]}},"alternative-id":["10.1136\/openhrt-2026-004340"],"URL":"https:\/\/doi.org\/10.1136\/openhrt-2026-004340","relation":{},"ISSN":["2053-3624"],"issn-type":[{"value":"2053-3624","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7]]}}}