DOI: https://doi.org/10.7705/biomedica.v36i2.2710

Multimorbilidad: bases conceptuales, modelos epidemiológicos y retos de su medición

Julián Alfredo Fernández-Niño, Eduardo Bustos-Vázquez

Resumen


El incremento continuo de pacientes con perfiles clínicos complejos debidos a enfermedades crónicas ha favorecido el uso cada vez más extendido del término multimorbilidad. Es indispensable disponer de una medición apropiada de esta condición, dado que representa un reto para el manejo clínico de los pacientes, los sistemas de salud y la investigación epidemiológica.
En este ensayo se revisan las propuestas conceptuales subyacentes a la medición de la multimorbilidad y se discuten los retos metodológicos involucrados, tomando como referencia las definiciones clásicas de comorbilidad, sus diferencias con el concepto de multimorbilidad y su papel en los estudios epidemiológicos, así como los distintos modelos conceptuales de los que se derivan las definiciones operativas y las estrategias de medición de dicha variable.
Se pudo determinar que hay una brecha importante entre el desarrollo del concepto de multimorbilidad y las definiciones operativas, a pesar del significativo avance teórico que ha permitido trascender la concepción clásica de comorbilidad para llegar al concepto actual de multimorbilidad. Sin embargo, las estrategias de medición no se han desarrollado al mismo ritmo del concepto, por lo que se requieren nuevas propuestas metodológicas que permitan obtener información sobre su verdadero impacto en la salud de las personas y sus implicaciones para la salud pública.


Palabras clave


comorbilidad; enfermedad crónica; modelos teóricos; estudios epidemiológicos; sesgo (epidemiología); envejecimiento

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Referencias


1. Feinstein AR. The clinical design of statistics in therapy. Ann Intern Med. 1968;69:1287-312. http://dx.doi.org/10.7326/0003-4819-69-6-1287

2. Feinstein AR. The pre-therapeutic classification of co-morbidity in chronic disease. J Chron Dis. 1970;23:455-68. http://dx.doi.org/10.1016/0021-9681(70)90054-8

3. Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M. Multimorbidity´s many challenges. BMJ. 2007;334:1016-7. http://dx.doi.org/10.1136/bmj.39201.463819.2C

4. Fortin M, Lapointe L, Hudon C, Vanasse A. Multimorbidity is common to family practice. Is it commonly researched? Can Fam Physician. 2005;51:245.

5. Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: Implications for understanding health and health services. Ann Fam Med. 2009;7:357-63. http://dx.doi.org/10.1370/afm.983

6. Le Reste JY, Nabbe P, Manceau B, Lygidakis C, Doerr C, Lingner H, et al . The European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature. J Am Med Dir. 2013;14:319-25. http://dx.doi.org/10.1016/j.jamda.2013.01.001

7. Bayliss EA, Ellis JL, Shoup JA, Zeng C, McQuillan DB, Steiner JF. Association of patient-centered outcomes with patient-reported and ICD-9-based morbidity measures. Ann Fam Med. 2012;10:126-33. http://dx.doi.org/10.1370/afm.1364

8. Maciejewski ML, Bayliss EA. Approaches to comparative effectiveness research in multimorbid populations. Med Care. 2014;52:23-30. http://dx.doi.org/10.1097/MLR.0000000000000060

9. Bayliss EA, Ellis JL, Steiner JF. Barriers to self-management and quality of life outcomes in seniors with multimorbidities. Ann Fam Med. 2007;5:395-402. http://dx.doi.org/10.1370/afm.722

10. Kaplan MH, Feinstein AR. The importance of classifying initial co-morbidity in evaluating the outcome of diabetes mellitus. J Chron Dis. 1974;27:387-404. http://dx.doi.org/10.1016/0021-9681(74)90017-4

11. Bernabeu-Wittel M, Ollero-Baturone M, Nieto-Martín D, García-Morillo S, Goicoechea-Salazar J. Patient-centered care for older adults with multiple chronic conditions: These are the polypathological patients! J Am Geriatr Soc. 2013; 61:475-6. http://dx.doi.org/10.1111/jgs.12142

12. Brandlmeier P. Multimorbidity among elderly patients in an urban general practice. ZFA (Stuttgart). 1976;52:1269-75.

13. World Health Organization. The World Health Report 2008. Primary Health Care. Now more than ever. New York: The World Health Report; 2008. p. 14.

14. Batstra L, Bos EH, Neeleman J. Quantifying psychiatric comorbidity lessons from chronic disease epidemiology. Soc Psychiatr Epidemiol. 2002;37:105-11.

15. Perea-Martínez A, Bárcena-Sobrino E, Rodríguez-Herrera R, Greenawalt-Rodríguez S, Carbajal-Rodríguez L, Zarco-Román J. Obesidad y comorbilidades en niños y adolescentes asistidos en el Instituto Nacional de Pediatría. Acta Pediatr Mex. 2009;30:167-74.

16. Al-Delaimy AK, Al-Mekhlafi HM, Nasr NA, Sady H, Atroosh WM, Nashiry M, et al . Epidemiology of intestinal polyparasitism among Orang Asli school children in rural Malaysia. PLoS Negl Trop Dis. 2014;8:e3074. http://dx.doi.org/10.1371/journal.pntd.0003074

17. Fernández-Niño JA, Idrovo AJ, Cucunubá ZM, Reyes-Harker P, Guerra ÁP, Moncada LI, et al . Paradoxical associations between soil-transmitted helminths and Plasmodium falciparum infection. Trans R Soc Trop Med Hyg. 2012;106:701-8. http://dx.doi.org/10.1016/j.trstmh.2012.07.012

18. Holguín-Acosta J, Osio-Uribe O, Sánchez-Mosquera Y, Carrioza-Moog G, Cornejo-Ochoa W. Comorbilidad del trastorno de hiperactividad con déficit de atención (THDA) en una muestra poblacional de niños y adolescentes escolares, Sabaneta, Colombia, 2001. Iatreia. 2007;20:101-10.

19. Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al . Aging with multimorbidity: A systematic review of the literature. Ageing Res. 2011;10:430-9. http://dx.doi.org/10.1016/j.arr.2011.03.003

20. Fortin M, Stewart M, Poitras ME, Almirall J, Maddocks H. A systematic review of prevalence studies on multimorbidity: Toward a more uniform methodology. Ann Fam Medicine. 2012;10:142-51. http://dx.doi.org/10.1370/afm.1337

21. van den Akker M, Buntinx F, Metsemakers JF, Roos S, Knottnerus JA. Multimorbidity in general practice: Prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol. 1998;51: 367-75. http://dx.doi.org/10.1016/s0895-4356(97)00306-5

22. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162:2269-76. http://dx.doi.org/10.1001/archinte.162.20.2269

23. Mollica RL, Gillespie J. Care coordination for people with chronic conditions- 2007. Fecha de consulta: 10 de enero de 2015. Disponible en: www.partnershipforsolutions.org/DMS/files/Care_coordination.pdf

24. Fortin M, Bravo G, Hudon C, Lapointe L, Almirall J, Dubois MF, et al . Relationship between multimorbidity and health-related quality of life of patients in primary care. Qual Life Res. 2006;15:83-91. http://dx.doi.org/10.1007/s11136-005-8661-z

25. Kent DM, Hayward RA, Griffith JL, Vijan S, Beshanky JR, Califf RM. An independently derived and validated predictive model for selecting patients with myocardial infarction who are likely to benefit from tissue plasminogen activator compared with streptokinase. Am J Med. 2002;113:104-11. http://dx.doi.org/10.1016/S0002-9343(02)01160-9

26. Kent DM, Ruthazer R, Selker HP. Are some patients likely to benefit from recombinant tissue-type plasminogen activator for acute ischemic stroke even beyond 3 hours from symptom onset? Stroke. 2003;34:464-7. http://dx.doi.org/10.1161/01.STR.0000051506.43212.8B

27. Kiernan M, Kraemer HC, Winkleby MA, King AC, Taylor CB. Do logistic regression and signal detection identify different subgroups at risk? Implications for the design of tailored interventions. Psychol Methods. 2001;6:35-48. http://dx.doi.org/10.1037/1082-989X.6.1.35

28. Zeng C, Ellis JL, Steiner JF, Shoup JA, McQuillan DB, Bayliss EA. Assessment of morbidity over time in predicting health outcomes. Med Care. 2014;52:52-9. http://dx.doi.org/10.1097/MLR.0000000000000033

29. Marengoni A, von Strass E, Rizzato D, Winblad B, Fratiglioni L. The impact of chronic multimorbidity and disability on functional decline and survival in elderly persons. A community-based, longitudinal study. J Intern Med. 2009;265:288-95. http://dx.doi.org/10.1111/j.1365-2796.2008.02017.x

30. Groll D, To T, Bombardier J, Wright JG. The development of a comorbidity index with physical function as the outcome. J Clin Epidemiol. 2005;58:595-602. http://dx.doi.org/10.1016/j.jclinepi.2004.10.018

31. Sullivan PW, Ghushchyan VH, Bayliss EA. The impact of co-morbidity burden on preference-based health-related quality of life in the United States. Pharmacoeconomics. 2012;30:431-42. http://dx.doi.org/10.2165/11586840-000000000-00000

32. Fortin M, Bravo G, Hudon C, Lapointe L, Dubois MF, Almirall J. Psychological distress and multimorbidity in primary care. Ann Fam Med. 2006;4:417-22. http://dx.doi.org/10.1370/afm.528

33. Walker AE. Multiple chronic diseases and quality of life: Patterns emerging from a large national sample, Australia. Chronic Illn. 2007;3:202-18. http://dx.doi.org/10.1177/1742395307081504

34. Loza E, Jover JA, Rodríguez L, Carmona L, EPISER Study Group. Multimorbidity: Prevalence, effect on quality of life and daily functioning, and variation of this effect when one condition is a rheumatic disease. Semin Arthritis Rheum. 2009;38:312-9. http://dx.doi.org/10.1016/j.semarthrit.2008.01.004

35. Wong SY, Mercer SW, Woo J, Leung J. The influence of multi-morbidity and self-reported socio-economic standing on the prevalence of depression in an elderly Hong Kong population. BMC Public Health. 2008;8:119. http://dx.doi.org/10.1186/1471-2458-8-119

36. Gunn JM, Ayton DR, Densley K, Pallant JF, Chondros P, Herrman HE, et al . The association between chronic illness, multimorbidity and depressive symptoms in an Australian primary care cohort. Soc Psychiatry Epidemiol. 2012;47:175-84. http://dx.doi.org/10.1007/s00127-010-0330-z

37. Tabarés-Seisdedos R, Valderas JM. Inverse comorbidity: The power of paradox in the advancement of science. Journal of Comorbidity. 2013;3:1-3. http://dx.doi.org/10.15256/joc.2013.3.19

38. Working Group on Health Outcomes for Older Persons with Multiple Chronic Conditions. Universal health outcome measures for older persons with multiple chronic conditions. J Am Geriatr Soc. 2012;60:2333-41. http://dx.doi.org/10.1111/j.1532-5415.2012.04240.x

39. Menotti A, Mulder I, Nissinen A, Giampaoli S, Feskens EJ, Kromhout D. Prevalence of morbidity and multimorbidity in elderly male populations and their impact on 10-year all-cause mortality: The FINE study (Finland, Italy, Netherlands Elderly). J Clin Epidemiol. 2001;54:680-6. http://dx.doi.org/10.1016/S0895-4356(00)00368-1

40. Deeg DJ, Portrait F, Lindeboom M. Health profiles and profile-specific health expectancies of older women and men: The Netherlands. J Women Aging. 2002;14:27-46. http://dx.doi.org/10.1300/J074v14n01_03

41. Noël PH, Frueh BC, Larme AC, Pugh JA. Collaborative care needs and preferences of primary care patients with multimorbidity. Health Expect. 2005;8:54-63. http://dx.doi.org/10.1111/j.1369-7625.2004.00312.x

42. Friedman B, Jiang HJ, Elixhauser A, Segal A. Hospital inpatient costs for adults with multiple chronic conditions. Med Care Res Rev. 2006;63:327-46. http://dx.doi.org/10.1177/1077558706287042

43. Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry.1999;40:57-87.

44. Piette JD, Kerr EA. The impact of comorbid chronic conditions on diabetes care. Diabetes Care. 2006;29:725-31. http://dx.doi.org/10.2337/diacare.29.03.06.dc05-2078

45. Redelmeier DA, Tan SH, Booth GL. The treatment of unrelated disorders in patients with chronic medical diseases. N Engl J Med. 1998;338:1516-20. http://dx.doi.org/10.1056/NEJM199805213382106

46. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA. 2005;294:716-24. http://dx.doi.org/10.1001/jama.294.6.716

47. Nardi R, Scanelli G, Corrao S, Iori I , Mathieu G, Cataldi Amatrian R. Comorbidity does not reflect complexity in internal medicine patients. Eur J Intern Med. 2007;18:359-68. http://dx.doi.org/10.1016/j.ejim.2007.05.002

48. Safford MM, Allison JJ, Kiefe CI. Patient complexity: More than comorbidity. The vector model of complexity. J Gen Intern Med. 2007;22:382-90. http://dx.doi.org/10.1007/s11606-007-0307-0

49. Diederichs C, Berger K, Bartels DB. The measurement of multiple chronic diseases �a systematic review on existing multimorbidity indices. J Gerontol A Biol Sci Med Sci. 2011;66:301-11. http://dx.doi.org/10.1093/gerona/glq208

50. Schram MT, Frijters D, van de Lisdonk EH, Ploemacher J, de Craen AJ, de Waal MW, et al . Setting and registry characteristics affect the prevalence and nature of multi-morbidity in the elderly. J Clin Epidemiol. 2008;61:1104-12. http://dx.doi.org/10.1016/j.jclinepi.2007.11.021

51. 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;380:37-43. http://dx.doi.org/10.1016/S0140-6736(12)60240-2

52. Rijken M, van Kerkhof M, Dekker J, Schellevis FG. Comorbidity of chronic diseases. Qual Life Res. 2005;14:45-55. http://dx.doi.org/10.1007/s11136-004-0616-2

53. Britt HC, Harrison CM, Miller GC, Knox SA. Prevalence and patterns of multimorbidity in Australia. Med J Aust. 2008;189:72-7.

54. Idler EL, Benyamini Y. Self-rated health and mortality: A review of twenty-seven community studies. J Health Soc Behav. 1997;38:21-37.

55. Barros Marilisa BA, Zanchetta Luane M, Moura Erly C, Malta DC. Auto-avaliação da saúde e fatores associados, Brasil, 2006. Rev Saúde Pública. 2009;43:27-37. http://dx.doi.org/10.1590/S0034-89102009000900005

56. Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med. 2009;69:307-16. http://dx.doi.org/10.1016/j.socscimed.2009.11.003

57. Mercer SW, Smith SM, Wyke S, O´Dowd T, Watt GC. Multimorbidity in primary care: Developing the research agenda. J Fam Pract. 2009;26:79-80. http://dx.doi.org/10.1093/fampra/cmp020

58. Crabtree HL, Gray CS, Hildreth HJ, O´Connell JE, Brown J. The Comorbidity Symptom Scale: A combined disease inventory and assessment of symptoms severity. J Am Geriatr Soc. 2000;48:1674-8. http://dx.doi.org/10.1111/j.1532-5415.2000.tb03882.x

59. Sangha O, Stucki G, Liang MH, Fossel AH, Katz JN. The self-administered comorbidity questionnaire: A new method to assess comorbidity for clinical and health services research. Arthritis Rheum. 2003;49:156-63. http://dx.doi.org/10.1002/art.10993

60. Charlson ME, Pompei P, Ales KL, MacKenzie R. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987; 40:373-83.

61. Holman CD, Preen DB, Baynham NJ, Finn JC, Semmens JB. A multipurpose comorbidity scoring system performed better than the Charlson Index. J Clin Epidemiol. 2005;58:1006-14. http://dx.doi.org/10.1016/j.jclinepi.2005.01.020

62. von Korff M, Wagner EH, Saunders K. A chronic disease score from automated pharmacy data. J Clin Epidemiol. 1992;45:197-203. http://dx.doi.org/10.1016/0895-4356(92) 90016-G

63. Alonso-Morán E, Nuño-Solinís R, Onder G, Tonnara G. Multimorbidity in risk stratification tools to predict negative outcomes in adult population. Eur J Intern Med. 2015;26:182-9. http://dx.doi.org/10.1016/j.ejim.2015.02.010

64. van den Akker M, Buntinx F, Roos S, Knottnerus JA. Problems in determining occurrence rates of multimorbidity. J Clin Epidemiol. 2001;54:675-9. http://dx.doi.org/10.1016/S0895-4356(00)00358-9

65. Marengoni A, Rizzuto D, Wang HX, Winblad B, Fratiglioni L. Patterns of chronic multimorbidity in the elderly population. J Am Geriatr Soc. 2009;57:225-30. http://dx.doi.org/10.1111/j.1532-5415.2008.02109.x

66. Prados-Torres A, Calderón-Larrañaga A, Hancco-Saavedra J, Poblador-Plou B, van den Akker M. Multimorbidity patterns: A systematic review. J Clin Epidemiol. 2014;67:254-66. http://dx.doi.org/10.1016/j.jclinepi.2013.09.021

67. Kim DJ, Westfall AO, Chamot E, Willig AL, Mugavero MJ, Ritchie C, et al . Multimorbidity patterns in HIV-infected patients: The role of obesity in chronic disease clustering. J Acquir Immune Defic Syndr. 2012;61:600-5. http://dx.doi.org/10.1097/QAI.0b013e31827303d5

68. Oni T, McGrath N, BeLue R, Roderick P, Colagiuri S, May CR, et al . Chronic diseases and multi-morbidity - a conceptual modification to the WHO ICCC model for countries in health transition. BMC Public Health. 2014;9:575. http://dx.doi.org/10.1186/1471-2458-14-575

69. Orueta JF, García-Álvarez A, García-Goñi M, Paolucci F, Nuño-Solinís R. Prevalence and costs of multimorbidity by deprivation levels in the Basque country: A population based study using health administrative databases. PLoS One. 2014;9:e89787. http://dx.doi.org/10.1371/journal.pone.008978


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