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By Martin Fortin

Professor Barbara Starfield, a prominent figure in primary care and other fields, died suddenly in California on Friday 10 June 2011. My colleagues and I would like to express our sincere condolences to her family, friends and colleagues.

Dr. Starfield made landmark contributions in primary care. The coexistence of multiple diseases did not escape her attention. Before the introduction of the concept of multimorbidity, Dr. Starfield realized that people should be characterized by their morbidity burden, and her work led to the development of an important methodological tool for assessing diagnosed morbidity burden: the Adjusted Clinical Groups system.¹ With its use, populations can be described according to the mix of types of all conditions they experience in any given time period (including signs and symptoms as well as all types of diagnoses).

The subjects of comorbidity and multimorbidity are present in several of her publications,^2-5 and my colleagues and I had the privilege of motivating her to write an editorial on one of our publications.⁶

In the June 9, 2011 posting that precedes this one, I brought to your attention the essential ideas I found in her last editorial published this year, which was also dedicated to co- and multi-morbdity.⁷ In essence, she alerted us to the fact that “it is not chronicity per se that creates a burden on the health-care system… it is the number of types of conditions, that is, multi-morbidity “.⁷ I believe it is our duty to honour her visionary statement and carry on her legacy.

Thank you Dr. Starfield for your inspiration.

1. Starfield B, Weiner J, Mumford L, Steinwachs D. Ambulatory care groups: a categorization of diagnoses for research and management. Health Services Research. 1991;26(1):53-74.
2. Starfield B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner JP. Comorbidity: implications for the importance of primary care in ‘case’ management. Ann Fam Med. May-Jun 2003;1(1):8-14.
3. Starfield B, Lemke KW, Herbert R, Pavlovich WD, Anderson G. Comorbidity and the use of primary care and specialist care in the elderly. Ann Fam Med. 2005;3:215-222.
4. Valderas JM, Starfield B, Roland M. Multimorbidity’s many challenges: A research priority in the UK. BMJ. Jun 2 2007;334(7604):1128.
5. Starfield B. Co-morbidity and its challenges for quality of primary care. Rev Port Clin Geral. 2007;223:179-180.
6. Starfield B. Threads and yarns: weaving the tapestry of comorbidity. Ann Fam Med. 2006;4:101-103.
7. Starfield B. Challenges to primary care from co- and multi-morbidity. Prim Health Care Res Dev. 2011;12:1-2.

By Martin Fortin

Searching for articles published on multimorbidity this year, it has been nice to note that already there is an important new body of information covering different aspects of the subject. I would like to share with you blog visitors the titles of the most relevant publications found, along with the links to the abstracts:

–          Marengoni A et al. Aging with multimorbidity: A systematic review of the literature. Ageing Res Rev Mar 23 [Epub ahead of print] 2011. [PubMed abstract]

–          Salisbury C et al. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract 2011;61:e12-21. [PubMed abstract]

–          Bower P et al. Multimorbidity, service organization and clinical decision making in primary care: a qualitative study. Fam Pract May 25 [Epub ahead of print] 2011. [PubMed abstract]

–          Tucker-Seeley RD et al. Lifecourse socioeconomic circumstances and multimorbidity among older adults. BMC Public Health 2011;11:313. [PubMed abstract]

–          Wong A et al. Longitudinal administrative data can be used to examine multimorbidity, provided false discoveries are controlled for. J Clin Epidemiol Mar 29 [Epub ahead of print] 2011. [PubMed abstract]

–          Galenkamp H et al. Somatic Multimorbidity and Self-rated Health in the Older Population. J Gerontol B Psychol Sci Soc Sci 2011;66:380-6. [PubMed abstract]

–          Glynn LG et al. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract Mar 24 [Epub ahead of print] 2011. [PubMed abstract]

–          Drewes YM et al. The effect of cognitive impairment on the predictive value of multimorbidity for the increase in disability in the oldest old: the Leiden 85-plus Study. Age Ageing 2011;40:352-7. [PubMed abstract]

–          Holzhausen M et al. Operationalizing multimorbidity and autonomy for health services research in aging populations–the OMAHA study. BMC Health Serv Res 2011;11:47. [PubMed abstract]

–          Morris RL et al. Shifting priorities in multimorbidity: a longitudinal qualitative study of patient’s prioritization of multiple conditions. Chronic Illn 2011;7:147-61. [PubMed abstract]

–          van den Bussche H et al. Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany. BMC Public Health 2011;11:101. [PubMed abstract]

–          Schüz B et al. Medication beliefs predict medication adherence in older adults with multiple illnesses. J Psychosom Res 37(6):565-74 2011;70:179-87. [PubMed abstract]

–          Schäfer I et al. Multimorbidity patterns in the elderly: a new approach of disease clustering identifies complex interrelations between chronic conditions. PLoS ONE 2010;5:e15941. [PubMed abstract]

–          Gunn JM et al. The association between chronic illness, multimorbidity and depressive symptoms in an Australian primary care cohort. Soc Psychiatry Psychiatr Epidemiol Dec 25 [Epub ahead of print] 2010. [PubMed abstract]

–          Thiem U et al. Prerequisites for a new health care model for elderly people with multimorbidity: the PRISCUS research consortium. Z Gerontol Geriatr 2011;44:115-20. [PubMed abstract]

–          Naessens JM et al. Effect of multiple chronic conditions among working-age adults. Am J Manag Care 2011;17:118-22. [PubMed abstract]

–          Diederichs C et al. The Measurement of Multiple Chronic Diseases–A Systematic Review on Existing Multimorbidity Indices. J Gerontol A Biol Sci Med Sci 2011;66:301-11. [PubMed abstract]

–          Lupari M et al. We’re just not getting it right’–how should we provide care to the older person with multi-morbid chronic conditions? J Clin Nurs 2011;20. [PubMed abstract]

–          Starfield B. Challenges to primary care from co- and multi-morbidity. Prim Health Care Res Dev 2011;12:1-2. [Full text]

A comment on each of these publications is not possible here. However, I want to bring to your attention the main idea I found in the last publication on the list, which is an editorial by Barbara Starfield:

“…it is not chronic conditions by themselves that raise resource use. Rather, it is the number of types of conditions, that is, multi-morbidity.”

“…despite the attention to chronic diseases in many countries of the world, it is not chronicity per se that creates a burden on the health-care system.”

It’s worth reading entirely!

All publications are included in our library. Feel free to share with anyone interested in multimorbidity.

Martin