Multimorbidity: Through a Glass Darkly

  • Carmel M. MartinEmail author


This chapter firstly provides an overview of multimorbidity as a complicated clinico-epidemiological, yet reductionist construct of multiple discreet disease(s) occurring in one individual. Current multimorbidity studies highlight taxonomic challenges about the actual nature of disease or chronic disease singly or in clusters and their underlying processes, and clinical practices. Multimorbidity is then viewed through the lens of systems medicine in the future, as multi-layered complex adaptive systems health care. Systems medicine is an interdisciplinary field of science which studies the nature and processes of complex systems of the biological sciences, as well as in information technology applied to medicine. Networks and psychoneuroimmunology and social phenomena form another “branch” of systems medicine. Nevertheless, clinico-epidemiological multi-morbidity, systems medicine and psychoneuroimmunology are very far apart in the literature with few intersecting research publications, despite commonality in the use of biomarkers and biometrics. As multimorbidity care will inevitably embrace new knowledge and technologies, it is important to improve personal- and population-centred care, rather than biomarker and biometrics reductionism. Opportunities must be embraced to transcend fragmented silos of knowledge and reductionistic care into integrated systems from biomarkers to clinical and population networks that help improve individual care.


System Biology System Medicine Prevalence Female Wide Social Network Reductionistic Care 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    International Research Community on Multimorbidity. The definition of multimorbidity: looking for a consensus. Cited Accessed 3 Oct 2014.
  2. 2.
    Feinstein A. The pre-therapeutic classification of co-morbidity in chronic disease. J Chronic Dis. 1970;23(7):455–68.CrossRefPubMedGoogle Scholar
  3. 3.
    Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009;7(4):357–63.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    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(3):254–66.CrossRefPubMedGoogle Scholar
  5. 5.
    France E, Wyke S, Gunn J, Mair F, McLean G, Mercer S. Multimorbidity in primary care: a systematic review of prospective cohort studies. Br J Gen Pract. 2012;62(597):e297–307.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Britt H, Harrison C, Miller G, Knox S. Prevalence and patterns of multimorbidity in Australia. Med J Aust. 2008;189:72–77.PubMedGoogle Scholar
  7. 7.
    McDaid O, Hanly MJ, Richardson K, Kee F, Kenny RA, Savva GM. The effect of multiple chronic conditions on self-rated health, disability and quality of life among the older populations of Northern Ireland and the Republic of Ireland: a comparison of two nationally representative cross-sectional surveys. BMJ Open. 2013;3(6):e002571.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Harrison C, Britt H, Miller G, Henderson J. Examining different measures of multimorbidity, using a large prospective cross-sectional study in Australian general practice. BMJ Open. 2014;4(7):e004694.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Violán C, Foguet-Boreu Q, Roso-Llorach A, Rodriguez-Blanco T, Pons-Vigués M, Pujol-Ribera E, Muñoz-Pérez M and Valderas J. Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study. BMC Public Health. 2014;14:530.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Marengoni A, von Strauss E, Rizzuto 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(2):288–95.CrossRefPubMedGoogle Scholar
  11. 11.
    Lappenschaar M, Hommersom A, Lucas PJ. Probabilistic causal models of multimorbidity concepts. AMIA Annu Symp Proc. 2012;2012:475–84.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. Br Med J. 2012;345:e5205.CrossRefGoogle Scholar
  13. 13.
    Barnett K, Mercer S, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multi-morbidity and implications for health care, research and medical education: a cross-sectional study. Lancet. 2012;380(9836):37–43.CrossRefPubMedGoogle Scholar
  14. 14.
    Mercer S. Multimorbidity and the inverse care law in primary care. Br Med J. 2012;344:e4152.CrossRefGoogle Scholar
  15. 15.
    Galenkamp H, Braam AW, Huisman M, Deeg DJ. Somatic multimorbidity and self-rated health in the older population. J Gerontol B Psychol Sci Soc Sci. 2011;66(3):380–86.CrossRefPubMedGoogle Scholar
  16. 16.
    Nobrega TC, Jaluul O, Machado AN, Paschoal SM, Jacob Filho W. Quality of life and multimorbidity of elderly outpatients. Clinics (Sao Paulo). 2009;64(1):45–50.CrossRefGoogle Scholar
  17. 17.
    Martin CM, Peterson C. The social construction of chronicity–a key to understanding chronic care transformations. J Eval Clin Pract. 2009;15(3):578–85.CrossRefPubMedGoogle Scholar
  18. 18.
    Bayliss EA, Ellis JL, Steiner JF. Seniors’ self-reported multimorbidity captured biopsychosocial factors not incorporated into two other data-based morbidity measures. J Clin Epidemiol. 2009;62(5):550–7.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Martin CM. The care of chronic illness in general practice. Ph.D. Thesis. Canberra: Australian National University; 1998.Google Scholar
  20. 20.
    Kline TJ, Willness C, Ghali WA. Predicting patient complaints in hospital settings. Qual Saf Health Care. 2008;17(5):346–50.CrossRefPubMedGoogle Scholar
  21. 21.
    Voorham J, Denig P. Groningen initiative to analyse type 2 diabetes treatment. Computerized extraction of information on the quality of diabetes care from free text in electronic patient records of general practitioners. J Am Med Inform Assoc. 2007;14(3):349–54.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Kontopantelis E, Springate DA, Ashworth M, Webb RT, Buchan IE, Doran T. Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study. Br Med J. 2015;350:h904.CrossRefGoogle Scholar
  23. 23.
    McLean G, Sutton M, Guthrie B. Deprivation and quality of primary care services: evidence for persistence of the inverse care law from the UK Quality and Outcomes Framework. J Epidemiol Community Health. 2006;60(11):917–22.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Federoff HJ, Gostin LO. Evolving from reductionism to holism: is there a future for systems medicine? JAMA. 2009;302(9):994–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Juster RP, McEwen BS, Lupien SJ. Allostatic load biomarkers of chronic stress and impact on health and cognition. Neurosci Biobehav Rev. 2010;35(1):2–16.CrossRefPubMedGoogle Scholar
  26. 26.
    Westerhoff HV, Palsson BO. The evolution of molecular biology into systems biology. Nat Biotechnol. 2004;22(10):1249–52.CrossRefPubMedGoogle Scholar
  27. 27.
    Martin CM, Peterson C. The social construction of chronicity - a key to understanding chronic care transformations. J Eval Clin Pract. 2009;15(3):578–85.CrossRefPubMedGoogle Scholar
  28. 28.
    Armstrong D. The emancipation of biographical medicine. Soc Sci Med. 1979;13:1–8.Google Scholar
  29. 29.
    Engel GL. The biopsychosocial model and the education of health professionals. Gen Hosp Psychiatry. 1979;1(2):156–65.CrossRefPubMedGoogle Scholar
  30. 30.
    Yancik R, Ershler W, Satariano W, Hazzard W, Cohen HJ, Ferrucci L. Report of the National Institute on aging task force on comorbidity. J Gerontol A Biol Sci Med Sci. 2007;62(3): 275–80.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Sturmberg JP, Martin CM. Diagnosis - the limiting focus of taxonomy. J Eval Clin Pract. 2015. Accessed 21 Dec 2015 [online version 2014].
  32. 32.
    van der Heijden MJ, Schroen Y. Global advances in health and medicine through systems biology: an example from the Netherlands. Global Adv Health Med. 2012;1(4):92–3.CrossRefGoogle Scholar
  33. 33.
    Strauss VY, Jones PW, Kadam UT, Jordan KP. Distinct trajectories of multimorbidity in primary care were identified using latent class growth analysis. J Clin Epidemiol. 2014;67(10):1163–71.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Baylis D, Bartlett DB, Syddall HE, Ntani G, Gale CR, Cooper C, et al. Immune-endocrine biomarkers as predictors of frailty and mortality: a 10-year longitudinal study in community-dwelling older people. Age (Dordr.) 2013;35(3):963–71.CrossRefGoogle Scholar
  35. 35.
    Förhécz Z, Gombos T, Borgulya G, Pozsonyi Z, Prohászka Z, Jánoskuti L. Red cell distribution width in heart failure: prediction of clinical events and relationship with markers of ineffective erythropoiesis, inflammation, renal function, and nutritional state. Am. Heart J 2009;158(4):659–66.CrossRefPubMedGoogle Scholar
  36. 36.
    Peters S, Janssen H-G, Vivő-Truyols G. Trend analysis of time-series data: a novel method for untargeted metabolite discovery. Anal Chim Acta. 2010;663(1):98–104.CrossRefPubMedGoogle Scholar
  37. 37.
    Cole SW. Social regulation of human gene expression: mechanisms and implications for public health. Am J Public Health. 2013;103 Suppl 1:S84–92.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Christian LM, Glaser R, Porter K, Malarkey WB, Beversdorf D, Kiecolt-Glaser JK. Poorer self-rated health is associated with elevated inflammatory markers among older adults. Psychoneuroendocrinology. 2011;36(10):1495–1504.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Jylhä M, Volpato S, Guralnik J. Self-rated health showed a graded association with frequently used biomarkers in a large population sample. J Clin Epidemiol. 2006;59:465–71.CrossRefPubMedGoogle Scholar
  40. 40.
    Juster RP, Marin MF, Sindi S, Nair NP, Ng YK, Pruessner JC, Lupien SJ. Allostatic load associations to acute, 3-year and 6-year prospective depressive symptoms in healthy older adults. Physiol Cehavior. 2011;104(2):360–64.CrossRefGoogle Scholar
  41. 41.
    Picard M, Juster R, Sabiston C. Is the whole greater than the sum of the parts? Self-rated health and transdisciplinarity. Health. 2013;5:24–30.CrossRefGoogle Scholar
  42. 42.
    Salanitro AH, Ritchie CS, Hovater M, Roth DL, Sawyer P, Locher JL, et al. Inflammatory biomarkers as predictors of hospitalization and death in community-dwelling older adults. Arch Gerontol Geriatr. 2012;54(3):e387–91.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Vanfleteren LE, Spruit MA, Groenen M, Gaffron S, van Empel VP, Bruijnzeel PL, Rutten EP, Op’t Roodt J, Wouters EF, Franssen FM. Clusters of comorbidities based on validated objective measurements and systemic inflammation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2013;187(7):728–35.CrossRefPubMedGoogle Scholar
  44. 44.
    Melis R, Marengoni A, Angleman S, Fratiglioni L. Incidence and predictors of multimorbidity in the elderly: a population-based longitudinal study. PloS One. 2014;9(7):e103120.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Kurtz C, Snowden D. The new dynamics of strategy: Sense-making in a complex and complicated world. IBM Syst J. 2003;42(3):462–83.CrossRefGoogle Scholar
  46. 46.
    Morgan WK. Letter: Medical-industrial complex. Lancet. 1974;1(7847):96.CrossRefPubMedGoogle Scholar
  47. 47.
    Relman AS. The new medical-industrial complex. N Engl J Med. 1980;303(17):963–70.CrossRefPubMedGoogle Scholar
  48. 48.
    Halfon N, Larson K, Lu M, Tullis E, Russ S. Lifecourse health development: past, present and future. Matern Child Health J. 2014;18(2):344–65.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Martin CM, Vogel C, Grady D, Zarabzadeh A, Hederman L, Kellett J, et al. Implementation of complex adaptive chronic care: the Patient Journey Record system (PaJR). J Eval Clin Pract. 2012;18(6):1226–34.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of Public Health and Primary CareTrinity College, College GreenDublin 2Ireland

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