Review Article

Journal of General Internal Medicine

, Volume 29, Issue 3, pp 529-537

Quality of Care for Patients with Multiple Chronic Conditions: The Role of Comorbidity Interrelatedness

  • Donna M. ZulmanAffiliated withCenter for Health Care Evaluation, VA Palo Alto Health Care SystemDivision of General Medical Disciplines, Department of Internal Medicine, Stanford University Email author 
  • , Steven M. AschAffiliated withCenter for Health Care Evaluation, VA Palo Alto Health Care SystemDivision of General Medical Disciplines, Department of Internal Medicine, Stanford University
  • , Susana B. MartinsAffiliated withGeriatrics Research Education and Clinical Center, VA Palo Alto Health Care System
  • , Eve A. KerrAffiliated withCenter for Clinical Management Research, VA Ann Arbor Healthcare SystemDepartment of Internal Medicine, University of Michigan
  • , Brian B. HoffmanAffiliated withVA Boston Health Care System, West Roxbury DivisionHarvard Medical School
  • , Mary K. GoldsteinAffiliated withGeriatrics Research Education and Clinical Center, VA Palo Alto Health Care SystemCenter for Primary Care and Outcomes Research, Stanford University

ABSTRACT

Multimorbidity—the presence of multiple chronic conditions in a patient—has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient’s number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relationship between multimorbidity and quality of care, and discuss how this relationship may be mediated by the degree to which conditions interact with one another to generate clinical complexity (comorbidity interrelatedness). Drawing on established theoretical frameworks from cognitive engineering and biomedical informatics, we describe how interactions among conditions result in clinical complexity and may affect quality of care. We discuss how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics, and describe opportunities to quantify this construct using data widely available through electronic health records. Incorporating comorbidity interrelatedness into conceptualizations of multimorbidity has the potential to enhance clinical and research efforts that aim to improve care for patients with multiple chronic conditions.