The disease burden of multimorbidity and its interaction with educational level

Abstract

Introduction: Policies to adequately respond to the rise in multimorbidity have top-priority. To understand the actual burden of multimorbidity, this study aimed to: 1) estimate the trend in prevalence of multimorbidity in the Netherlands, 2) study the association between multimorbidity and physical and mental health outcomes and healthcare cost, and 3) investigate how the association between multimorbidity and health outcomes interacts with socio-economic status (SES).

Methods: Prevalence estimates were obtained from a nationally representative pharmacy database over 2007-2016. Impact on costs was estimated in a fixed effect regression model on claims data over 2009-2015. Data on physical and mental health and SES were obtained from the National Health Survey in 2017, in which the Katz-10 was used to measure limitations in activities of daily living (ADL) and the Mental Health Inventory (MHI) to measure mental health. SES was approximated by the level of education. Generalized linear models (2-part models for ADL) were used to analyze the health data. In all models an indicator variable for the presence or absence of multimorbidity was included or a categorical variable for the number of chronic conditions. Interactions terms of multimorbidity and educational level were added into the previously mentioned models.

Results: Over the past ten years, there was an increase of 1.6%-point in the percentage of people with multimorbidity. The percentage of people with three or more conditions increased with +2.1%-point. People with multimorbidity had considerably worse physical and mental health outcomes than people without multimorbidity. For the ADL, the impact of multimorbidity was three times greater in the lowest educational level than in the highest educational level. For the MHI, the impact of multimorbidity was two times greater in the lowest than in the highest educational level. Each additional chronic condition was associated with a greater worsening in health outcomes. Similarly, for costs, where there was no evidence of a diminishing impact of additional conditions either. In patients with multimorbidity total healthcare costs were on average €874 higher than in patients with a single morbidity.

Conclusion: The impact of multimorbidity on health and costs seems to be greater in the sicker and lower educated population.

Fig 1. Change in prevalence or multimorbidity by age groups compared to 2007.

Fig 2. Change in prevalence of different numbers of chronic conditions compared to 2007.

Fig 3. Difference in ADL score compared to no morbidity across education levels.

The number of participants is 7,741. The group without a chronic condition is the reference group. *: A higher score indicates a worse ADL. The standard error bars were based on bootstrapping. **Education level: 1 for primary school; 2 for Pre-vocational training; 3 for High school or vocational training; 4 for Higher education until Bachelor; 5 for Master/doctorate.

Fig 4. Difference in MHI score compared to no morbidity across education levels.

The number of participants is 7,741. The group without a chronic condition is the reference group. *: A lower score indicates a worse mental health. The standard error bars were based on bootstrapping. **Education level: 1 for primary school; 2 for Pre-vocational training; 3 for High school or vocational training; 4 for Higher education until Bachelor; 5 for Master/doctorate.