Quality of Life Research

, Volume 25, Issue 10, pp 2619–2632 | Cite as

The relative impact of chronic conditions and multimorbidity on health-related quality of life in Ontario long-stay home care clients

  • Luke Mondor
  • Colleen J. Maxwell
  • Susan E. Bronskill
  • Andrea Gruneir
  • Walter P. Wodchis



To examine the relative impact of 16 common chronic conditions and increasing morbidity on health-related quality of life (HRQL) in a population-based sample of home care clients in Ontario, Canada.


Participants were adult clients assessed with the Resident Assessment Instrument for Home Care (RAI-HC) between January and June 2009 and diagnosed with one (or more) of 16 common chronic conditions. HRQL was evaluated using the Minimum Data Set-Health Status Index (MDS-HSI), a preference-based measure derived from items captured in the RAI-HC. Multivariable linear regression models assessed the relative impact of each condition, and increasing number of diagnoses, on MDS-HSI scores.


Mean (SD) MDS-HSI score in the study population (n = 106,159) was 0.524 (0.213). Multivariable analysis revealed a statistically significant (p < 0.05) and clinically important (difference ≥ 0.03) decrease in MDS-HSI scores associated with stroke (−0.056), osteoarthritis (−0.036), rheumatoid arthritis (−0.033) and congestive heart failure (CHF, −0.030). Differences by age and sex were observed; most notably, the negative impact associated with dementia was greater among men (−0.043) than among women (−0.019). Further, HRQL decreased incrementally with additional diagnoses. In all models, chronic conditions and number of diagnoses accounted for a relatively small proportion of the variance observed in MDS-HSI.


Clinically important negative effects on HRQL were observed for clients with a previous diagnosis of stroke, osteo- and rheumatoid arthritis, or CHF, as well as with increasing levels of multimorbidity. Findings provide baseline preference-based HRQL scores for home care clients with different diagnoses and may be useful for identifying, targeting and evaluating care strategies toward populations with significant HRQL impairments.


Chronic disease Home care services Quality of life Health status Ontario/epidemiology 



This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the MOHLTC is intended or should be inferred. Further, parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI.

Compliance with ethical standards

Conflict of interest



  1. 1.
    Barnett, K., Mercer, S. W., Norbury, M., Watt, G., Wyke, S., & Guthrie, B. (2012). Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. Lancet, 380, 37–43.PubMedCrossRefGoogle Scholar
  2. 2.
    Pearson, W. S., Bhat-Schelbert, K., & Probst, J. C. (2012). Multiple chronic conditions and the aging of America: Challenge for primary care physicians. Journal of Primary Care & Community Health, 3(1), 51–56.CrossRefGoogle Scholar
  3. 3.
    World Health Organization. (2011). Global status report on noncommunicable diseases: 2010, 1–176. [Cited 2016 Mar 17]
  4. 4.
    Salive, M. E. (2013). Multimorbidity in older adults. Epidemiologic Reviews, 35, 75–83.PubMedCrossRefGoogle Scholar
  5. 5.
    Thorpe, K. E., Ogden, L. L., & Galactionova, K. (2010). Chronic conditions account for rise in medicare spending from 1987 to 2006. Health Affairs, 29(4), 718–724.PubMedCrossRefGoogle Scholar
  6. 6.
    Hung, W. W., Ross, J. S., Boockvar, K. S., & Siu, A. L. (2011). Recent trends in chronic disease, impairment and disability among older adults in the United States. BMC Geriatrics, 11(1), 47.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Uijen, A. A., & van de Lisdonk, E. H. (2008). Multimorbidity in primary care: Prevalence and trend over the last 20 years. European Journal of General Practice, 14(s1), 28–32.PubMedCrossRefGoogle Scholar
  8. 8.
    Daar, A. S., Singer, P. A., Leah Persad, D., Pramming, S. K., Matthews, D. R., Beaglehole, R., et al. (2007). Grand challenges in chronic non-communicable diseases. Nature, 450(7169), 494–496.PubMedCrossRefGoogle Scholar
  9. 9.
    Wolff, J. L., Starfield, B., & Anderson, G. (2002). Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Archives of Internal Medicine, 162(20), 2269–2276.PubMedCrossRefGoogle Scholar
  10. 10.
    Glynn, L. G., Valderas, J. M., Healy, P., Burke, E., Newell, J., Gillespie, P., & Murphy, A. W. (2011). The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Family Practice, 28(5), 516–523.PubMedCrossRefGoogle Scholar
  11. 11.
    Bähler, C., Huber, C. A., Brüngger, B., & Reich, O. (2015). Multimorbidity, health care utilization and costs in an elderly community-dwelling population: A claims data based observational study. BMC Health Services Research, 15(1), 23.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Rijken, M., van Kerkhof, M., Dekker, J., & Schellevis, F. G. (2005). Comorbidity of chronic diseases: Effects of disease pairs on physical and mental functioning. Quality of Life Research, 14(1), 45–55.PubMedCrossRefGoogle Scholar
  13. 13.
    Tinetti, M. E., McAvay, G. J., Chang, S. S., Newman, A. B., Fitzpatrick, A. L., Fried, T. R., & Peduzzi, P. N. (2011). Contribution of multiple chronic conditions to universal health outcomes. Journal of the American Geriatrics Society, 59(9), 1686–1691.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Feeny, D. (2013). Health-related quality-of-life data should be regarded as a vital sign. Journal of Clinical Epidemiology, 66(7), 706–709.PubMedCrossRefGoogle Scholar
  15. 15.
    Agborsangaya, C. B., Lau, D., Lahtinen, M., Cooke, T., & Johnson, J. A. (2012). Health-related quality of life and healthcare utilization in multimorbidity: Results of a cross-sectional survey. Quality of Life Research, 22(4), 791–799.PubMedCrossRefGoogle Scholar
  16. 16.
    Hunger, M., Thorand, B., Schunk, M., Döring, A., Menn, P., Peters, A., & Holle, R. (2011). Multimorbidity and health-related quality of life in the older population: Results from the German KORA-age study. Health and Quality of Life Outcomes, 9(1), 53.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Schultz, S. E., & Kopec, J. A. (2003). Impact of chronic conditions. Health Reports, 14(4), 41–53.PubMedGoogle Scholar
  18. 18.
    Parker, L., Moran, G. M., Roberts, L. M., Calvert, M., & McCahon, D. (2014). The burden of common chronic disease on health-related quality of life in an elderly community-dwelling population in the UK. Family Practice, 31(5), 557–563.PubMedCrossRefGoogle Scholar
  19. 19.
    Franks, P., Hanmer, J., & Fryback, D. G. (2006). Relative disutilities of 47 risk factors and conditions assessed with seven preference-based health status measures in a national U.S. Sample. Medical Care, 44(5), 478–485.PubMedCrossRefGoogle Scholar
  20. 20.
    Saarni, S. I., Härkänen, T., Sintonen, H., Suvisaari, J., Koskinen, S., Aromaa, A., & Lönnqvist, J. (2006). The impact of 29 chronic conditions on health-related quality of life: A general population survey in Finland using 15D and EQ-5D. Quality of Life Research, 15(8), 1403–1414.PubMedCrossRefGoogle Scholar
  21. 21.
    Saarni, S. I., Suvisaari, J., Sintonen, H., Koskinen, S., Härkänen, T., & Lönnqvist, J. (2007). The health-related quality-of-life impact of chronic conditions varied with age in general population. Journal of Clinical Epidemiology, 60(12), 1288–1297.PubMedCrossRefGoogle Scholar
  22. 22.
    Tsasis, P. (2009). Chronic disease management and the home-care alternative in Ontario Canada. Health Services Management Research, 22(3), 136–139.PubMedCrossRefGoogle Scholar
  23. 23.
    Tsasis, P., & Bains, J. (2008). Management of complex chronic disease: Facing the challenges in the Canadian health-care system. Health Services Management Research, 21(4), 228–235.PubMedCrossRefGoogle Scholar
  24. 24.
    Health Quality Ontario. (2013). In-home care for optimizing chronic disease management in the community: An evidence-based analysis. Ontario Health Technology Assessment Series, 13(5), 1–65.Google Scholar
  25. 25.
    Hirdes, J. P., Fries, B. E., Morris, J. N., Steel, K., Mor, V., Frijters, D., et al. (1999). Integrated health information systems based on the RAI/MDS series of instruments. Healthcare Management Forum, 12(4), 30–40.PubMedCrossRefGoogle Scholar
  26. 26.
    Koné Pefoyo, A. J., Bronskill, S. E., Gruneir, A., Calzavara, A., Thavorn, K., Petrosyan, Y., et al. (2015). The increasing burden and complexity of multimorbidity. BMC Public Health, 15(1), 415.PubMedCentralCrossRefGoogle Scholar
  27. 27.
    Lane, N. E., Maxwell, C. J., Gruneir, A., Bronskill, S. E., & Wodchis, W. P. (2015). Absence of a socioeconomic gradient in older adults’ survival with multiple chronic conditions. EBIOM, 2(12), 2094–2100.CrossRefGoogle Scholar
  28. 28.
    Public Health Agency of Canada. (2010). The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2010, 1–151. [Cited 2016 Mar 17]
  29. 29.
    Public Health Agency of Canada. (2014). Economic Burden of Illness in Canada, 2005–2008 (pp. 1–111). [Cited 2016 Mar 17]
  30. 30.
    Canadian Institute for Health Information. (2010). Seniors and the Health Care System: What Is the Impact of Multiple Chronic Conditions? (pp. 1–23). [Cited 2016 Mar 17]
  31. 31.
    Austin, P. C., Daly, P. A., & Tu, J. V. (2002). A multicenter study of the coding accuracy of hospital discharge administrative data for patients admitted to cardiac care units in Ontario. American Heart Journal, 144(2), 290–296.PubMedCrossRefGoogle Scholar
  32. 32.
    Schultz, S. E., Rothwell, D. M., Chen, Z., & Tu, K. (2013). Identifying cases of congestive heart failure from administrative data: A validation study using primary care patient records. Chronic Diseases and Injuries in Canada, 33(3), 160–166.PubMedGoogle Scholar
  33. 33.
    Gershon, A. S., Wang, C., Guan, J., Vasilevska-Ristovska, J., Cicutto, L., & To, T. (2009). Identifying patients with physician-diagnosed asthma in health administrative databases. Canadian Respiratory Journal, 16(6), 183–188.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Gershon, A. S., Wang, C., Guan, J., Vasilevska-Ristovska, J., Cicutto, L., & To, T. (2009). Identifying individuals with physcian diagnosed COPD in health administrative databases. COPD: Journal of Chronic Obstructive Pulmonary Disease, 6(5), 388–394.PubMedCrossRefGoogle Scholar
  35. 35.
    Hux, J. E., Ivis, F., Flintoft, V., & Bica, A. (2002). Diabetes in Ontario: Determination of prevalence and incidence using a validated administrative data algorithm. Diabetes Care, 25(3), 512–516.PubMedCrossRefGoogle Scholar
  36. 36.
    Tu, K., Campbell, N. R., Chen, Z.-L., Cauch-Dudek, K. J., & McAlister, F. A. (2007). Accuracy of administrative databases in identifying patients with hypertension. Open Medicine, 1(1), e18–e26.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Tu, K., Wang, M., Young, J., Jaakkimainen, L., Ivers, N. M., Butt, D., et al. (2013). Validation of administrative data algorithms to determine population prevalence and incidence of Alzheimer’s disease, dementia, multiple sclerosis, epilepsy and Parkinson’s disease. A Report to the Public Health Agency of Canada.Google Scholar
  38. 38.
    Wodchis, W. P., Hirdes, J. P., & Feeny, D. H. (2003). Health-related quality of life based on the minimum data set. International Journal of Technology Assessment in Health Care, 19(3), 490–506.PubMedCrossRefGoogle Scholar
  39. 39.
    Furlong, W. J., Feeny, D. H., Torrance, G. W., & Barr, R. D. (2001). The Health Utilities Index (HUI) system for assessing health-related quality of life in clinical studies. Annals of Medicine, 33(5), 375–384.PubMedCrossRefGoogle Scholar
  40. 40.
    Drummond, M. (2001). Introducing economic and quality of life measurements into clinical studies. Annals of Medicine, 33(5), 344–349.PubMedCrossRefGoogle Scholar
  41. 41.
    Horsman, J., Furlong, W., Feeny, D., & Torrance, G. (2003). The Health Utilities Index (HUI): Concepts, measurement properties and applications. Health and Quality of Life Outcomes, 1, 54.
  42. 42.
    Kralj, B. (2009). Measuring Rurality—RIO2008_BASIC: Methodology and Results, 1–20. [Cited 2016 Mar 17]
  43. 43.
    Brettschneider, C., Leicht, H., Bickel, H., Dahlhaus, A., Fuchs, A., Gensichen, J., et al. (2013). Relative Impact of multimorbid chronic conditions on health-related quality of life—results from the MultiCare cohort study. PLoS One, 8(6), e66742.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Fortin, M., Lapointe, L., Hudon, C., Vanasse, A., Ntetu, A. L., & Maltais, D. (2004). Multimorbidity and quality of life in primary care: A systematic review. Health and Quality of Life Outcomes, 2, 51.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Lam, J. M. C., & Wodchis, W. P. (2010). The relationship of 60 disease diagnoses and 15 conditions to preference-based health-related quality of life in Ontario hospital-based long-term care residents. Medical Care, 48(4), 380–387.PubMedCrossRefGoogle Scholar
  46. 46.
    Fortin, M., Dubois, M.-F., Hudon, C., Soubhi, H., & Almirall, J. (2007). Multimorbidity and quality of life: A closer look. Health and Quality of Life Outcomes, 5(1), 52.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Morris, J. N., Fries, B. E., & Morris, S. A. (1999). Scaling ADLs within the MDS. Journal of Gerontology, 54(11), M546–M553.Google Scholar
  48. 48.
    Morris, J. N., Fries, B. E., Mehr, D. R., Hawes, C., Phillips, C., Mor, V., & Lipsitz, L. A. (1994). MDS cognitive performance scale. Journal of Gerontology, 49(4), M174–M182.PubMedCrossRefGoogle Scholar
  49. 49.
    Hirdes, J. P., Frijters, D. H., & Teare, G. F. (2003). The MDS-CHESS scale: A new measure to predict mortality in institutionalized older people. Journal of the American Geriatrics Society, 51(1), 96–100.PubMedCrossRefGoogle Scholar
  50. 50.
    Ovbiagele, B., Goldstein, L. B., Higashida, R. T., Howard, V. J., Johnston, S. C., Khavjou, O. A., et al. (2013). Forecasting the future of stroke in the United States: A policy statement from the American heart association and American stroke association. Stroke, 44(8), 2361–2375.PubMedCrossRefGoogle Scholar
  51. 51.
    Ferri, C. P., Prince, M., Brayne, C., Brodaty, H., Fratiglioni, L., Ganguli, M., et al. (2005). Global prevalence of dementia: A Delphi consensus study. The Lancet, 366(9503), 2112–2117.CrossRefGoogle Scholar
  52. 52.
    Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. (2004). Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care, 27(5), 1047–1053.PubMedCrossRefGoogle Scholar
  53. 53.
    Heidenreich, P. A., Trogdon, J. G., Khavjou, O. A., Butler, J., Dracup, K., Ezekowitz, M. D., et al. (2011). Forecasting the future of cardiovascular disease in the United States: A policy statement from the American heart association. Circulation, 123(8), 933–944.PubMedCrossRefGoogle Scholar
  54. 54.
    Perruccio, A. V., Power, J. D., & Badley, E. M. (2014). Revisiting arthritis prevalence projections—it’s more than just the aging of the population. The Journal of Rheumatology, 33(9), 1856–1862.Google Scholar
  55. 55.
    Maxwell, C. J., Kang, J., Walker, J. D., Zhang, J. X., Hogan, D. B., Feeny, D. H., & Wodchis, W. P. (2009). Sex differences in the relative contribution of social and clinical factors to the Health Utilities Index Mark 2 measure of health-related quality of life in older home care clients. Health and Quality of Life Outcomes, 7(1), 80.PubMedPubMedCentralCrossRefGoogle Scholar
  56. 56.
    Wodchis, W. P., Maxwell, C. J., Venturini, A., Walker, J. D., Zhang, J., Hogan, D. B., & Feeny, D. F. (2007). Study of observed and self-reported HRQL in older frail adults found group-level congruence and individual-level differences. Journal of Clinical Epidemiology, 60(5), 502–511.PubMedCrossRefGoogle Scholar
  57. 57.
    Thein, H.-H., Gomes, T., Krahn, M. D., & Wodchis, W. P. (2009). Health status utilities and the impact of pressure ulcers in long-term care residents in Ontario. Quality of Life Research, 19(1), 81–89.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Tonelli, S. M., Rakel, B. A., Cooper, N. A., Angstom, W. L., & Sluka, K. A. (2011). Women with knee osteoarthritis have more pain and poorer function than men, but similar physical activity prior to total knee replacement. Biology of Sex Differences, 2, 12.PubMedPubMedCentralCrossRefGoogle Scholar
  59. 59.
    Ahlstrand, I., Björk, M., Thyberg, I., & Falkmer, T. (2015). Pain and difficulties performing valued life activities in women and men with rheumatoid arthritis. Clinical Rheumatology, 34(8), 1353–1362.PubMedCrossRefGoogle Scholar
  60. 60.
    Fortin, M., Bravo, G., Hudon, C., Lapointe, L., Almirall, J., Dubois, M.-F., & Vanasse, A. (2006). Relationship between multimorbidity and health-related quality of life of patients in primary care. Quality of Life Research, 15(1), 83–91.PubMedCrossRefGoogle Scholar
  61. 61.
    Lochner, K., Goodman, R., Posner, S., & Parekh, A. (2013). Multiple chronic conditions among medicare beneficiaries: State-level variations in prevalence, utilization, and cost, 2011. Medicare & Medicaid Research Review, 3(3), E1–E19.CrossRefGoogle Scholar
  62. 62.
    Lochner, K. A., & Cox, C. S. (2013). Prevalence of multiple chronic conditions among medicare beneficiaries, United States, 2010. Preventing Chronic Disease, 10, 120137.
  63. 63.
    Goodman, R. A., Posner, S. F., Huang, E. S., Parekh, A. K., & Koh, H. K. (2013). Defining and measuring chronic conditions: Imperatives for research, policy, program, and practice. Preventing Chronic Disease, 10, 120239.
  64. 64.
    Reeve, B. B., Potosky, A. L., Smith, A. W., Han, P. K., Hays, R. D., Davis, W. W., et al. (2009). Impact of cancer on health-related quality of life of older americans. Journal of the National Cancer Institute, 101(12), 860–868.PubMedPubMedCentralCrossRefGoogle Scholar
  65. 65.
    Huguet, N., Kaplan, M. S., & Feeny, D. (2008). Socioeconomic status and health-related quality of life among elderly people: Results from the Joint Canada/United States survey of health. Social Science and Medicine, 66(4), 803–810.PubMedCrossRefGoogle Scholar
  66. 66.
    Robert, S. A., Cherepanov, D., Palta, M., Dunham, N. C., Feeny, D., & Fryback, D. G. (2009). Socioeconomic status and age variations in health-related quality of life: Results from the national health measurement study. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 64B(3), 378–389.PubMedCentralCrossRefGoogle Scholar
  67. 67.
    Lix, L., Yogendram, M., Burchill, C., Metge, C., McKeen, N., Moore, D., et al. (2006). Defining and Validating Chronic Diseases: An Administrative Data Approach (pp. 1–217). [Cited 2016 Mar 17]
  68. 68.
    Muggah, E., Graves, E., Bennett, C., & Manuel, D. G. (2013). Ascertainment of chronic diseases using population health data: A comparison of health administrative data and patient self-report. BMC Public Health, 13, 16.PubMedPubMedCentralCrossRefGoogle Scholar
  69. 69.
    Kane, R. A. (2003). Definition, measurement, and correlates of quality of life in nursing homes: Toward a reasonable practice, research, and policy agenda. The Gerontologist, 43(Suppl. 2), 28–36.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Luke Mondor
    • 1
    • 2
  • Colleen J. Maxwell
    • 1
    • 2
    • 3
  • Susan E. Bronskill
    • 1
    • 2
    • 4
  • Andrea Gruneir
    • 1
    • 2
    • 4
    • 5
  • Walter P. Wodchis
    • 1
    • 2
    • 4
    • 6
  1. 1.Institute for Clinical Evaluative Sciences (ICES)TorontoCanada
  2. 2.Health System Performance Research Network (HSPRN)TorontoCanada
  3. 3.Schools of Pharmacy and Public Health and Health SystemsUniversity of WaterlooWaterlooCanada
  4. 4.Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
  5. 5.Department of Family MedicineUniversity of AlbertaEdmontonCanada
  6. 6.Toronto Rehabilitation InstituteTorontoCanada

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