{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T04:24:06Z","timestamp":1790828646837,"version":"4.1.0"},"update-to":[{"DOI":"10.1371\/journal.pmed.1003584","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2021,5,10]],"date-time":"2021-05-10T00:00:00Z","timestamp":1620604800000}}],"reference-count":48,"publisher":"Public Library of Science (PLoS)","issue":"4","license":[{"start":{"date-parts":[[2021,4,26]],"date-time":"2021-04-26T00:00:00Z","timestamp":1619395200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Public Health France"}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Given the increasing burden of chronic conditions, multimorbidity is now a priority for healthcare and public health systems worldwide. Appropriate methodological approaches for assessing the phenomenon have not yet been established, resulting in inconsistent and incomplete descriptions. We aimed to estimate and characterize the burden of multimorbidity in the adult population in France in terms of number and type of conditions, type of underlying mechanisms, and analysis of the joint effects for identifying combinations with the most deleterious interaction effects on health status.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods and findings<\/jats:title>\n<jats:p>We used a multistep approach to analyze cross-sectional and longitudinal data from 2 large nationwide representative surveys: 2010\/2014 waves of the Health, Health Care, and Insurance Survey (ESPS 2010\u20132014) and Disability Healthcare Household Survey 2008 (HSM 2008), that collected similar data on 61 chronic or recurrent conditions. Adults aged \u226525 years in either ESPS 2010 (14,875) or HSM 2008 (23,348) were considered (participation rates were 65% and 62%, respectively). Longitudinal analyses included 7,438 participants of ESPS 2010 with follow-up for mortality (97%) of whom 3,798 were reinterviewed in 2014 (52%). Mortality, activity limitation, self-reported health, difficulties in activities\/instrumental activities of daily living, and Medical Outcomes Study Short-Form 12-Item Health Survey were the health status measures. Multiple regression models were used to estimate the impact of chronic or recurrent conditions and multimorbid associations (dyads, triads, and tetrads) on health status. Etiological pathways explaining associations were investigated, and joint effects and interactions between conditions on health status measures were evaluated using both additive and multiplicative scales.<\/jats:p>\n<jats:p>Forty-eight chronic or recurrent conditions had an independent impact on mortality, activity limitations, or perceived heath. Multimorbidity prevalence varied between 30% (1-year time frame) and 39% (lifetime frame), and more markedly according to sex (higher in women), age (with greatest increases in middle-aged), and socioeconomic status (higher in less educated and low-income individuals and manual workers). We identified various multimorbid combinations, mostly involving vasculometabolic and musculoskeletal conditions and mental disorders, which could be explained by direct causation, shared or associated risk factors, or less frequently, confounding or chance. Combinations with the highest health impacts included diseases with complications but also associations of conditions affecting systems involved in locomotion and sensorial functions (impact on activity limitations), and associations including mental disorders (impact on perceived health). The interaction effects of the associated conditions varied on a continuum from subadditive and additive (associations involving cardiometabolic conditions, low back pain, osteoporosis, injury sequelae, depression, and anxiety) to multiplicative and supermultiplicative (associations involving obesity, chronic obstructive pulmonary disease, migraine, and certain osteoarticular pathologies). Study limitations included self-reported information on chronic conditions and the insufficient power of some analyses.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Multimorbidity assessments should move beyond simply counting conditions and take into account the variable impacts on health status, etiological pathways, and joint effects of associated conditions. In particular, the multimorbid combinations with substantial health impacts or shared risk factors deserve closer attention. Our findings also suggest that multimorbidity assessment and management may be beneficial already in midlife and probably earlier in disadvantaged groups.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pmed.1003584","type":"journal-article","created":{"date-parts":[[2021,4,26]],"date-time":"2021-04-26T19:38:47Z","timestamp":1619465927000},"page":"e1003584","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":39,"title":["Estimating and characterizing the burden of multimorbidity in the community: A comprehensive multistep analysis of two large nationwide representative surveys in France"],"prefix":"10.1371","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9588-2189","authenticated-orcid":true,"given":"Jo\u00ebl","family":"Coste","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9299-1555","authenticated-orcid":true,"given":"Jos\u00e9 M.","family":"Valderas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1556-8590","authenticated-orcid":true,"given":"Laure","family":"Carcaillon-Bentata","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2021,4,26]]},"reference":[{"key":"pmed.1003584.ref001","doi-asserted-by":"crossref","first-page":"1859","DOI":"10.1016\/S0140-6736(18)32335-3","article-title":"Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990\u20132017: a systematic analysis for the Global Burden of Disease Study 2017","volume":"392","author":"GBD 2017 DALYs and HALE Collaborators","year":"2018","journal-title":"Lancet"},{"key":"pmed.1003584.ref002","doi-asserted-by":"crossref","first-page":"65","DOI":"10.3109\/13814789609162146","article-title":"Comorbidity or multimorbidity: what\u2019s in a name? A review of literature","volume":"2","author":"M van den Akker","year":"1996","journal-title":"Eur J Gen Pract"},{"key":"pmed.1003584.ref003","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1016\/S0895-4356(97)00306-5","article-title":"Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases","volume":"51","author":"M van den Akker","year":"1998","journal-title":"J Clin Epidemiol"},{"key":"pmed.1003584.ref004","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1186\/1477-7525-7-82","article-title":"Prevalence of multiple chronic conditions in the United States\u2019 Medicare population","volume":"7","author":"KM Schneider","year":"2009","journal-title":"Health Qual Life Outcomes"},{"key":"pmed.1003584.ref005","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/S0140-6736(12)60240-2","article-title":"Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study","volume":"380","author":"K Barnett","year":"2012","journal-title":"Lancet"},{"key":"pmed.1003584.ref006","doi-asserted-by":"crossref","first-page":"860","DOI":"10.1007\/s12603-016-0802-2","article-title":"Pre-Frailty, Frailty, and Multimorbidity: Prevalences and Associated Characteristics from Two French National Surveys","volume":"20","author":"C Le Cossec","year":"2016","journal-title":"J Nutr Health Aging"},{"key":"pmed.1003584.ref007","doi-asserted-by":"crossref","first-page":"2235042X19870934","DOI":"10.1177\/2235042X19870934","article-title":"Prevalence of multimorbidity in community settings: A systematic review and meta-analysis of observational studies","volume":"9","author":"H Nguyen","year":"2019","journal-title":"J Comorb"},{"key":"pmed.1003584.ref008","doi-asserted-by":"crossref","first-page":"e102149","DOI":"10.1371\/journal.pone.0102149","article-title":"Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies","volume":"9","author":"C Violan","year":"2014","journal-title":"PLoS ONE"},{"key":"pmed.1003584.ref009","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1016\/j.jclinepi.2013.09.021","article-title":"Multimorbidity patterns: a systematic review","volume":"67","author":"A Prados-Torres","year":"2014","journal-title":"J Clin Epidemiol"},{"key":"pmed.1003584.ref010","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1370\/afm.983","article-title":"Defining comorbidity: implications for understanding health and health services","volume":"7","author":"JM Valderas","year":"2009","journal-title":"Ann Fam Med"},{"key":"pmed.1003584.ref011","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1016\/j.archger.2016.07.008","article-title":"Multimorbidity and mortality in older adults: A systematic review and meta-analysis","volume":"67","author":"B Pererira Nunes","year":"2016","journal-title":"Arch Gerontol Geriatr"},{"key":"pmed.1003584.ref012","doi-asserted-by":"crossref","first-page":"e1002503","DOI":"10.1371\/journal.pmed.1002503","article-title":"Trajectories of functional decline in older adults with neuropsychiatric and cardiovascular multimorbidity: A Swedish cohort study","volume":"15","author":"DL Vetrano","year":"2018","journal-title":"PLoS Med"},{"key":"pmed.1003584.ref013","first-page":"1","article-title":"Enqu\u00eate sur la sant\u00e9 et la protection sociale (ESPS) 2010","volume":"553","author":"P Dourgnon","year":"2012","journal-title":"Rapports de l\u2019IRDES"},{"key":"pmed.1003584.ref014","first-page":"1","article-title":"Une approche de l\u2019autonomie chez les adultes et les personnes \u00e2g\u00e9es. Premiers r\u00e9sultats de l\u2019enqu\u00eate Handicap-Sant\u00e9 2008","volume":"718","author":"S Dos Santos","year":"2010","journal-title":"Etudes et r\u00e9sultats"},{"key":"pmed.1003584.ref015","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1186\/s12963-017-0126-4","article-title":"Evidence-based design recommendations for prevalence studies on multimorbidity: improving comparability of estimates","volume":"15","author":"BM Holzer","year":"2017","journal-title":"Popul Health Metr"},{"key":"pmed.1003584.ref016","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1093\/eurpub\/13.suppl_1.6","article-title":"Euro-REVES Group. Creating a coherent set of indicators to monitor health across Europe: the Euro-REVES 2 project","volume":"13","author":"JM Robine","year":"2003","journal-title":"Eur J Public Health"},{"key":"pmed.1003584.ref017","doi-asserted-by":"crossref","first-page":"914","DOI":"10.1001\/jama.1963.03060120024016","article-title":"Studies of illness in the aged. The Index of ADL: a standardized measure of biological and psychosocial function","volume":"185","author":"S Katz","year":"1963","journal-title":"JAMA"},{"key":"pmed.1003584.ref018","first-page":"179","article-title":"Assessment of older people: Self-maintenance and Instrumental Activities of Daily Living","volume":"9","author":"M Lawton","year":"1969","journal-title":"Gerontology"},{"key":"pmed.1003584.ref019","doi-asserted-by":"crossref","first-page":"1171","DOI":"10.1016\/S0895-4356(98)00109-7","article-title":"Cross-validation of Item Selection and Scoring for the SF-12 Health Survey in Nine Countries: Results From the IQOLA Project. International Quality of Life Assessment","volume":"51","author":"B Gandek","year":"1998","journal-title":"J Clin Epidemiol"},{"key":"pmed.1003584.ref020","volume-title":"International classification of functioning, disability and health","author":"World Health Organization","year":"2001"},{"key":"pmed.1003584.ref021","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1016\/j.arr.2011.03.003","article-title":"Aging with multimorbidity: A systematic review of the literature","volume":"10","author":"A Marengoni","year":"2011","journal-title":"Ageing Res Rev"},{"key":"pmed.1003584.ref022","doi-asserted-by":"crossref","DOI":"10.1201\/9781315155074","volume-title":"Perceived health and adaptation in chronic disease","author":"F Guillemin","year":"2017","edition":"1"},{"key":"pmed.1003584.ref023","doi-asserted-by":"crossref","DOI":"10.1007\/978-3-319-19425-7","volume-title":"Regression modeling strategies: with applications to linear models, logistic and ordinal regression, and survival analysis","author":"FE Harrell","year":"2015","edition":"2"},{"key":"pmed.1003584.ref024","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1002\/bimj.201700067","article-title":"Variable selection\u2014A review and recommendations for the practicing statistician","volume":"60","author":"G Heinze","year":"2018","journal-title":"Biom J"},{"key":"pmed.1003584.ref025","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1186\/s41512-020-00074-3","article-title":"for TG2 of the STRATOS initiative. State of the art in selection of variables and functional forms in multivariable analysis-outstanding issues","volume":"4","author":"W Sauerbrei","year":"2020","journal-title":"Diagn Progn Res"},{"key":"pmed.1003584.ref026","doi-asserted-by":"crossref","first-page":"648","DOI":"10.1097\/EDE.0000000000001054","article-title":"The Interaction Continuum","volume":"30","author":"TJ VanderWeele","year":"2019","journal-title":"Epidemiology"},{"key":"pmed.1003584.ref027","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1515\/em-2013-0005","article-title":"A Tutorial on Interaction","volume":"3","author":"TJ VanderWeele","year":"2014","journal-title":"Epidemiol Methods"},{"key":"pmed.1003584.ref028","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1093\/aje\/kwn104","article-title":"On the estimation of additive interaction by use of the four-by-two table and beyond","volume":"168","author":"GY Zou","year":"2008","journal-title":"Am J Epidemiol"},{"key":"pmed.1003584.ref029","unstructured":"Sant\u00e9 publique France. G\u00e9odes. Observatoire cartographique des indicateurs \u00e9pid\u00e9miologiques. Available from: https:\/\/geodes.santepubliquefrance.fr\/ [cited 2020 November 1]."},{"key":"pmed.1003584.ref030","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1186\/s12916-019-1305-x","article-title":"Relationship between multimorbidity, demographic factors and mortality: findings from the UK Biobank cohort","volume":"17","author":"BD Jani","year":"2019","journal-title":"BMC Med"},{"key":"pmed.1003584.ref031","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1186\/s12889-015-1733-2","article-title":"The increasing burden and complexity of multimorbidity","volume":"15","author":"AJ Pefoyo","year":"2015","journal-title":"BMC Public Health"},{"key":"pmed.1003584.ref032","doi-asserted-by":"crossref","first-page":"e028333","DOI":"10.1136\/bmjopen-2018-028333","article-title":"Increasing age- and gender-specific burden and complexity of multimorbidity in Taiwan, 2003\u20132013: a cross-sectional study based on nationwide claims data","volume":"9","author":"RH Hu","year":"2019","journal-title":"BMJ Open"},{"key":"pmed.1003584.ref033","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1186\/s12916-020-01543-8","article-title":"Characteristics, service use and mortality of clusters of multimorbid patients in England: a population-based study","volume":"18","author":"Y Zhu","year":"2020","journal-title":"BMC Med."},{"key":"pmed.1003584.ref034","doi-asserted-by":"crossref","first-page":"776","DOI":"10.1186\/s12889-015-2008-7","article-title":"Multimorbidity and the inequalities of global ageing: a cross-sectional study of 28 countries using the World Health Surveys","volume":"15","author":"S Afshar","year":"2015","journal-title":"BMC Public Health"},{"key":"pmed.1003584.ref035","unstructured":"Centers for Disease Control and Prevention. BRFSS Prevalence and Trends data. Available from: https:\/\/www.cdc.gov\/brfss\/brfssprevalence\/index.html [cited 2020 November 1]."},{"key":"pmed.1003584.ref036","unstructured":"Public Health England. Public Health Profiles. Available from: https:\/\/fingertips.phe.org.uk\/ [cited 2020 November 1]."},{"key":"pmed.1003584.ref037","doi-asserted-by":"crossref","first-page":"112","DOI":"10.3109\/02813432.2016.1153242","article-title":"The role of diseases, risk factors and symptoms in the definition of multimorbidity\u2014a systematic review","volume":"34","author":"TG Willadsen","year":"2016","journal-title":"Scand J Prim Health Care"},{"key":"pmed.1003584.ref038","doi-asserted-by":"crossref","first-page":"604","DOI":"10.1016\/S1470-2045(11)70041-9","article-title":"No paradox, no progress: inverse cancer comorbidity in people with other complex diseases","volume":"12","author":"R Tabar\u00e9s-Seisdedos","year":"2011","journal-title":"Lancet Oncol"},{"key":"pmed.1003584.ref039","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1017\/S146342361700041X","article-title":"Comorbidity indices: a call for the integration of physical and mental health","volume":"19","author":"MA Nowels","year":"2018","journal-title":"Prim Health Care Res Dev"},{"key":"pmed.1003584.ref040","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1186\/s12889-019-6567-x","article-title":"The prevalence of multimorbidity and associations with lifestyle factors among middle-aged Canadians: an analysis of Canadian Longitudinal Study on Aging data","volume":"19","author":"MN Sakib","year":"2019","journal-title":"BMC Public Health"},{"key":"pmed.1003584.ref041","first-page":"e1003094","article-title":"Multimorbidity, mortality, and HbA1c in type 2 diabetes: A cohort study with UK and Taiwanese cohorts","volume":"17","author":"JI Chiang","journal-title":"PLoS Med. 2020"},{"key":"pmed.1003584.ref042","doi-asserted-by":"crossref","first-page":"514","DOI":"10.1093\/ije\/dyr218","article-title":"Recommendations for presenting analyses of effect modification and interaction","volume":"41","author":"MJ Knol","year":"2012","journal-title":"Int J Epidemiol"},{"key":"pmed.1003584.ref043","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1186\/1471-2458-13-251","article-title":"Comparison of the information provided by electronic health records data and a population health survey to estimate prevalence of selected health conditions and multimorbidity","volume":"13","author":"C Viol\u00e1n","year":"2013","journal-title":"BMC Public Health"},{"key":"pmed.1003584.ref044","first-page":"710","article-title":"Cholest\u00e9rol LDL chez les adultes en France m\u00e9tropolitaine: concentration moyenne, connaissance et traitement en 2015, \u00e9volutions depuis 2006","volume":"37","author":"C Lecoffre","year":"2018","journal-title":"Bull Epid\u00e9miol Hebd"},{"key":"pmed.1003584.ref045","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1370\/afm.1337","article-title":"A systematic review of prevalence studies on multimorbidity: toward a more uniform methodology","volume":"10","author":"M Fortin","year":"2012","journal-title":"Ann Fam Med"},{"key":"pmed.1003584.ref046","doi-asserted-by":"crossref","first-page":"1107","DOI":"10.1093\/ije\/25.6.1107","article-title":"Basic Methods for Sensitivity Analysis of Biases","volume":"25","author":"S Greenland","year":"1996","journal-title":"Int J Epidemiol"},{"key":"pmed.1003584.ref047","doi-asserted-by":"crossref","first-page":"e018986","DOI":"10.1136\/bmjopen-2017-018986","article-title":"Comparative analysis of methods for identifying multimorbidity patterns: a study of \u2018real-world\u2019 data","volume":"8","author":"A Roso-Llorach","year":"2018","journal-title":"BMJ Open"},{"key":"pmed.1003584.ref048","doi-asserted-by":"crossref","first-page":"976","DOI":"10.1093\/ije\/18.4.976","article-title":"Analytical implications of epidemiological concepts of interaction","volume":"18","author":"N Pearce","year":"1989","journal-title":"Int J Epidemiol"}],"updated-by":[{"DOI":"10.1371\/journal.pmed.1003584","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2021,5,10]],"date-time":"2021-05-10T00:00:00Z","timestamp":1620604800000}}],"container-title":["PLOS Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1003584","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,5,10]],"date-time":"2021-05-10T19:14:37Z","timestamp":1620674077000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1003584"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,4,26]]},"references-count":48,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2021,4,26]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pmed.1003584","relation":{"new_version":[{"id-type":"doi","id":"10.1371\/journal.pmed.1003584","asserted-by":"object"}]},"ISSN":["1549-1676"],"issn-type":[{"value":"1549-1676","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,4,26]]}}}