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The Measurement of Multimorbidity

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DOI: 10.1037/hea0000739

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Health Psychology
The Measurement of Multimorbidity
Kathryn Nicholson, José Almirall, and Martin Fortin
Online First Publication, April 25, 2019. http://dx.doi.org/10.1037/hea0000739

CITATION
Nicholson, K., Almirall, J., & Fortin, M. (2019, April 25). The Measurement of Multimorbidity. Health
Psychology. Advance online publication. http://dx.doi.org/10.1037/hea0000739
 Health Psychology
© 2019 American Psychological Association 2019, Vol. 2, No. 999, 000
0278-6133/19/$12.00 http://dx.doi.org/10.1037/hea0000739

The Measurement of Multimorbidity

Kathryn Nicholson José Almirall and Martin Fortin

Western University Université de Sherbrooke and Centre intégré universitaire de
santé et de services sociaux du Saguenay-Lac-St-Jean,
Quebec, Canada

Overview: The presence of multiple concurrent medical conditions (also known as multimorbidity) is
now a common phenomenon, hence the importance of its measurement. Objective: The purpose of this
paper is to review the multimorbidity measures that have been published in the literature to date and that
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

are available for use in future research studies. Method: Two main groups of measures of multimorbidity
This document is copyrighted by the American Psychological Association or one of its allied publishers.

could be distinguished. The first group of measures is constituted by a simple count from various lists
of chronic conditions. The second group of measures introduces a weighting for included chronic
conditions thus creating a “weighted index” of multimorbidity. These groups are not mutually exclusive
as the list of medical conditions in some weighted indices can be used as a list of conditions without
weighting. This article includes a review of the multimorbidity literature to date that has reported these
groups of measurements, showing the variety of existing measurements and highlighting their differences
to provide an overview of the possibilities that are available to a researcher intending to measure
multimorbidity. Conclusion: Finally, we outline some guidelines for the choice of a measurement of
multimorbidity for research studies. We hope that this review of the existing literature will help inform
the careful use of these tools by researchers moving forward. In addition to this review, it is advised that
readers attempt to keep updated on the ever-increasing multimorbidity literature.

Keywords: multimorbidity, multiple concurrent medical conditions, measurement

Supplemental materials: http://dx.doi.org/10.1037/hea0000739.supp

The presence of multiple concurrent medical conditions is a
common phenomenon in clinical and community settings (Afshar,
Roderick, Kowal, Dimitrov, & Hill, 2015; Fortin, Stewart, Poitras,
Almirall, & Maddocks, 2012; Ryan et al., 2018), and acknowl-
edged as the rule rather than the exception in primary care (Fortin,
Bravo, Hudon, Vanasse, & Lapointe, 2005). This fact implies that
the presence of multiple medical conditions should be taken into
account and measured in research studies. Important reasons for
measuring the presence of multiple medical conditions in research
are: (a) to identify any change in prevalence or characteristics of
multimorbidity, (b) to correct for the potential confounding effects
of multimorbidity, (c) to predict outcomes that are relevant for
patients and the health care system, and (d) to improve statistical
efficiency by categorizing all co-occurring medical conditions into
one variable (de Groot, Beckerman, Lankhorst, & Bouter, 2003;
Griffith et al., 2018).
Kathryn Nicholson, Department of Epidemiology and Biostatistics,
Schulich School of Medicine and Dentistry, Centre for Studies in Family
Medicine, Western University; José Almirall and Martin Fortin, Depart-
ment of Family Medicine and Emergency Medicine, Université de Sher-
brooke, and Centre intégré universitaire de santé et de services sociaux du
Saguenay-Lac-St-Jean, Quebec, Canada.
Correspondence concerning this article should be addressed to Martin
Fortin, Centre intégré universitaire de santé et de services sociaux du
Saguenay-Lac-St- Jean, 305 St-Vallier, Chicoutimi, Québec, G7H 5H6,
Canada. E-mail: Martin.Fortin@usherbrooke.ca
There are two prominent ways of addressing the presence of
coexisting medical conditions. One way is to focus on a single
medical condition, which is then called the index medical condi-
tion. This disease-specific approach leads to the concept of comor-
bidity, which refers to “any distinct additional clinical entity that
has existed or that may occur during the clinical course of a patient
who has the index disease under study” (Feinstein, 1970, p. 456).
Although additional medical conditions may affect the course of
the index condition, they are considered of less importance (Figure
1). The other way of addressing the presence of multiple medical
conditions is the “generalist approach” that leads to the concept of
multimorbidity, which refers to any co-occurrence of diseases or
medical conditions without considering any as an index condition.
This way of addressing coexisting medical conditions implies a
patient-centered perspective that considers the overall impact of
the medical conditions on clinical outcomes that are important for
the patient (see Figure 1; van den Akker, Buntinx, & Knottnerus,
1996). The concepts of comorbidity and multimorbidity are not
only used in the domain of physical conditions but also in mental
conditions (North, Brown, & Pollio, 2016). Indeed, it has been
proposed that the multimorbidity perspective more accurately ap-
proaches real-world psychiatric care than the one of comorbid
diagnoses because it promotes a multifaceted perspective that
widens the field of practice (Bhalla & Rosenheck, 2018). At this
point, we should mention that the terms “comorbidity” and “mul-
timorbidity” have been used indistinctly to describe the coexis-
tence of multiple medical conditions for a long time (Nicholson et
al., 2019; van den Akker et al., 1996) creating some confusion

1
 2 NICHOLSON, ALMIRALL, AND FORTIN

Medical condition B
Disease-specific approach
Comorbidity

Coexisting conditions are of

less importance. Treatment Medical condition A Patient
seeks to induce remission of
the index condition.

Medical condition C
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Patient-centered approach Medical condition A

Multimorbidity

All conditions are of equal

importance. Treatment Medical condition B
oriented towards outcomes Patient
that matter to patient.

Medical condition C

Figure 1. Approaches to addressing the presence of coexistent medical conditions. The concept of comorbidity
implies a disease-specific approach and the associated medical interventions are addressed mainly to the index
condition (top). The concept of multimorbidity refers to a patient-centered approach and the primary interest
focuses on clinical outcomes that are important for the patient (bottom). See the online article for the color
version of this figure.

(Almirall & Fortin, 2013; van den Akker et al., 1996). Some
measures originally reported by authors as “comorbidity mea-
sures” are indeed “multimorbidity measures.” In this work, we will
focus on and refer to all tools as measures of multimorbidity,
which is a more general approach.
A recent analysis of the global scientific research on comorbid-
ity and multimorbidity conducted by Catalá-López and colleagues
(2018) identified and included a total of 85,994 papers (76,350
articles and 9,644 reviews). This review found that the most cited
papers, which were primarily focused on comorbidity, were pub-
lished in journals of psychiatry including the Journal of Clinical
Psychiatry and the Journal of Affective Disorders (Catalá-López et
al., 2018). However, the results of this review also indicate a need
for an enhanced study of multimorbidity to capture the full patient
perspective. In early co- and multimorbidity research, measures
were specifically developed for comorbidity associated with index
medical conditions such as diabetes (Kaplan & Feinstein, 1974),
stroke (Liu, Domen, & Chino, 1997), or ventricular fibrillation
(Hallstrom, Cobb, & Yu, 1996). Overall, however, most measures
were developed without a focus on a specific index medical
condition and can be used either to measure comorbidity (by
omitting the index medical condition from the measurement) or
multimorbidity (by including all medical conditions considered).
Numerous measures of specific multimorbidity have been reported
in the literature. A review conducted in 2003 identified 12 indices,
in addition to the simple count of chronic conditions (de Groot et
al., 2003), whereas another one from 2011 identified 39 indices
(Diederichs, Berger, & Bartels, 2011).
It is important for readers to understand two key elements of
multimorbidity research: the literature is expanding exponentially
(creating a need for researchers to keep up-to-date on recent
publications) and the measure of multimorbidity is not necessarily
meant to capture all elements of the associated burden experienced
by the patient (creating a need for a complement of measures that
are relevant to the study population). The purpose of this paper is
to provide a review of the literature published between 1974 to
2018 that have utilized measures for multimorbidity and to provide
guidance on measures to consider when conducting a research
study on multimorbidity.
Differences in the Development of
Multimorbidity Measures
In the existing multimorbidity literature, there are two main
groups of measures of multimorbidity that can be distinguished.
One group is created using a simple count from various lists of
chronic conditions. These measures are used to count the number
of chronic conditions present in study participants to correlate with
different outcomes. The second group of measures introduces a
weighting for chronic conditions. The latter is usually aimed at
predicting outcomes, such as physical functioning (Groll, To,
Bombardier, & Wright, 2005), resource utilization (Sangha,
Stucki, Liang, Fossel, & Katz, 2003), postoperative complications
(Greenfield, Apolone, McNeil, & Cleary, 1993), and mortality
(M. E. Charlson, Pompei, Ales, & MacKenzie, 1987). The primary
focus on chronic conditions, as compared with acute conditions or
 MEASUREMENT OF MULTIMORBIDITY
risk factors, is due to the ongoing need for management by patients
or caregivers and health care providers or a health professional
team (Mercer, Salisbury, & Fortin, 2014).
It is important to note that the broad classification of multimor-
bidity measures into two groups does not separate them into two
mutually exclusive categories because the list of medical condi-
tions in a weighted index can be used as a list of conditions without
weighting applied. Also, this classification does not include mea-
sures of multimorbidity which are not based on lists of medical
conditions. One measure of multimorbidity that is not captured by
this broad classification is the Cumulative Illness Rating Scale
(Linn, Linn, & Gurel, 1968), which includes 13 relatively inde-
pendent areas or domains that are grouped under body systems,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
instead of medical conditions. Another measure that does not fit
This document is copyrighted by the American Psychological Association or one of its allied publishers.
into the classification is the Adjusted Clinical Groups System
(Starfield & Kinder, 2011), which is based on 100 unique and
mutually exclusive combinations of conditions occurring in indi-
viduals over a period of time, usually 1 year. We have limited this
review to the measures of multimorbidity using lists of chronic
conditions as these are most prominent in the current multimor-
bidity literature and may be most relevant to understand the
conditions patients either have or are at risk of developing. Space
constraints did not permit an exhaustive listing of measures, and
preference was given to measures that have at least one of these
characteristics: extensively used, readily available, and relatively
easy to apply. Constructs not addressed in this paper (such as acute
conditions, symptoms, or body systems) may be integrated into
multimorbidity studies if deemed relevant by the research team.
Lists of Chronic Conditions
One problem that has hindered the comparability among multi-
morbidity studies is the diversity of chronic conditions in the lists
used, both in type and number (Fortin et al., 2012). Among the lists
of diagnoses reported in the literature, one can find numbers that
go from four (McGee, Cooper, Liao, & Durazo-Arvizu, 1996) to
102 (Holman, Preen, Baynham, Finn, & Semmens, 2005) diagno-
ses, and some lists have included acute medical conditions, symp-
toms, or risk factors along with chronic conditions (Holman et al.,
2005; Le Reste et al., 2013; Willadsen et al., 2016). Table 1 in the
online supplemental materials shows a sample of publications with
lists of diagnoses that provides an idea of their diversity regarding
the study population, subjects’ age, number of diagnoses, and
outcomes of interest. This table does not represent an exhaustive
review of lists published so far. The number of publications on
multimorbidity has been rising exponentially in the last few years
(McPhail, 2016), and the number of published lists has also in-
creased considerably.
Most lists of chronic conditions were developed to address
specific needs, mainly based on the outcome of interest. These
measures and associated references are included in Table 2 in the
online supplemental materials. Most of the lists have been used to
collect data by participant self-report, but in some studies, data
collection has been done through physician reports, medical re-
cords, or administrative data (Grimby & Svanborg, 1997; Holman
et al., 2005; Marengoni, von Strauss, Rizzuto, Winblad, &
Fratiglioni, 2009; Muggah, Graves, Bennett, & Manuel, 2012).
Importantly, the validity of the individual chronic conditions that
are included in the list for multimorbidity should be determined
3
and presented whenever possible. The accuracy of identifying
chronic conditions can be increased through the validation and
application of algorithms in the data (Tonelli et al., 2015). Unfor-
tunately, the majority of the lists were introduced in the literature
without the use of any specified selection criteria (Diederichs et
al., 2011). Indeed, the selection of medical conditions to be in-
cluded in a list is most often an arbitrary process, and even when
selection criteria are specified, they are always prone to criticism.
Regardless, the process of determining the selection criteria should
be made explicit in any publications, in order to allow for com-
parability and to ensure that the list used corresponds appropriately
with the sample population. A criterion frequently used by re-
searchers is to include the most prevalent conditions. However,
many lists of chronic conditions have been developed for studies in
elderly subjects Aged 65 years and older (Fillenbaum, Pieper,
Cohen, Cornoni-Huntley, & Guralnik, 2000; Forrest, Bunker,
Songer, Coben, & Cauley, 1997; Fried, Bandeen-Roche, Kasper,
& Guralnik, 1999; Fung et al., 2008; L. C. Min et al., 2007;
Schoenberg, Kim, Edwards, & Fleming, 2007), 75 years and older
(Fuchs et al., 1998; Grimby & Svanborg, 1997), or 80 years and
older (Cesari et al., 2006). The most prevalent conditions in these
age groups are not necessarily those found in younger subjects,
thus limiting their usefulness. Lists of chronic conditions that are
valid for use within younger subjects (that is, subjects under the
age of 65 years) are important because of the increasing burden of
multimorbidity in younger individuals (Ryan et al., 2018; Salis-
bury, Johnson, Purdy, Valderas, & Montgomery, 2011; Taylor et
al., 2010), particularly in deprived socioeconomic settings (Barnett
et al., 2012).
Researchers interested in creating a list of chronic conditions
may find that the seemingly simple designation of a disease or
medical condition as chronic can be confusing without a consistent
use of this classification term. The simplest definition of a chronic
condition is based only on the condition’s duration (minimal time
intervals of 3, 6, and 12 months have been suggested), but other
criteria such as pattern of recurrence or deterioration, prognosis,
consequences or sequelae, need for continuous medical treatment,
prevalence, and onset have also been suggested (Diederichs et al.,
2011; N=Goran et al., 2016; O’Halloran, Miller, & Britt, 2004;
Perrin et al., 1993; Stein, Bauman, Westbrook, Coupey, & Ireys,
1993). In this sense, efforts have been made to standardize the
definition of chronicity for use in research. O’Halloran and col-
leagues (2004) methodologically developed a list of 144 chronic
conditions based on the International Classification of Primary
Care (2nd ed.; ICPC-2; World Health Organization [WHO], 1998)
coding system by identifying characteristics that have been used to
define chronic conditions. Also using the ICPC-2, and based on a
consensus of practicing family physicians and criteria deemed
important to define chronic conditions, N=Goran and colleagues
(2016) established a list of 139 chronic conditions. From this list
of 139 chronic conditions, a total of 75 were deemed “most
relevant” within the context of multimorbidity, which means that
these conditions were considered most pertinent in a typical patient
living with multimorbidity (N=Goran et al., 2016). The criteria they
retained as important to define chronic conditions were duration,
sequelae, recurrence/pattern, and the diagnosis itself (N=Goran et
al., 2016). More recently, Calderon-Larranaga and colleagues
(2017) provided a clinically driven comprehensive list of 918
codes of the International Statistical Classification of Diseases
 4 NICHOLSON, ALMIRALL, AND FORTIN
and Related Health Problems (10th rev.; ICD-10; WHO, 2004)
grouped into 60 chronic disease categories. This list mainly aimed
to assess and measure multimorbidity in the older population, and
a condition was considered to be chronic if it had a prolonged
duration and either (a) left residual disability or worsening quality
of life; or (b) required a long period of care, treatment, or reha-
bilitation (Calderon-Larranaga et al., 2017).
Also recently, we developed a list of 20 chronic conditions or
categories of chronic conditions that were selected based on the
conditions’ relevance (that is, the frequency of encounters in
primary care), impact (that is, the amount of clinical care or
management required), and prevalence (that is, the frequency with
which it occurs within primary care patients) among the primary
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
care clientele (Fortin, Almirall, & Nicholson, 2017). The list was
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intended to be used in research studies in which the presence of
conditions would be documented by participant self-report, and
therefore, the length of the list was considered important to avoid
overwhelming patients with many diagnoses for specific chronic
conditions. In addition, the language was adapted to be answerable
by the majority of respondents, particularly those individuals with
lower health literacy. For example, several clinical diagnoses were
grouped into categories like “chronic musculoskeletal problem” or
“chronic urinary problem.” While the list includes only 20 chronic
condition items, in fact, the tool has also been mapped to 256
diagnostic codes of ICD-10 and 75 diagnostic codes of ICPC-2
that are available in clinical records (Fortin et al., 2017). A
systematic use of this instrument may improve comparability
among research studies. This multimorbidity instrument is pro-
vided in the online supplemental materials.
Mental health conditions have been represented in most of the
aforementioned lists of diagnoses used in studies on multimorbid-
ity and a list of reviewed studies in which mental health conditions
were captured is described in Table 3 in the online supplemental
materials. When measuring multimorbidity, it is desirable that the
instrument adequately captures its presence among study partici-
pants. In a systematic review on the prevalence of multimorbidity,
not much variation in prevalence (within approximately 10%)
across different ages was observed among studies that considered
at least 12 chronic conditions (Fortin et al., 2012). However, the
prevalence of multimorbidity was substantially underestimated
(between 20% and 40% lower than the more robust studies) in
those studies using shorter lists of conditions. Therefore, we may
say that longer lists of chronic conditions may be better to detect
multimorbidity in a sample, but a list of 12 chronic conditions is a
reasonable lower limit.
Weighted Indices
The so-called weighted indices are multimorbidity measures
including a list of medical conditions whose severity and/or impact
on the outcome of interest are considered in the variable of interest.
In some indices, factors besides the list of medical conditions are
also included, such as age (Fan et al., 2002; Incalzi et al., 1997),
severity of individual diseases (Mulrow, Gerety, Cornell, Law-
rence, & Kanten, 1994; Rozzini et al., 2002), limitation in func-
tioning (Sangha et al., 2003), and smoking status (Fan et al., 2002).
In all cases, the measurement involves the calculation of a final
score of the multimorbidity index. Weighted indices published up
to 2010 have been summarized in a systematic review (Diederichs
et al., 2011) and weighted indices that have been more recently
published are described in Table 4 in the online supplemental
materials.
The most prominent example of this group is the Charlson
Comorbidity Index (M. E. Charlson et al., 1987), which was
developed using a sample of patients admitted to a medical center
and with the outcome of 1-year mortality. This measure is most
frequently referenced in the current comorbidity and multimorbid-
ity literature with a total number of citations of 15,049 as of 2016
and an average of 518.9 citations per year (Catalá-López et al.,
2018). Adjusted relative risks assessing the risk of mortality for
patients with a given medical condition were employed as weights
for the different conditions and conditions with relative risks of 1.2
or lower were not considered. The final result was the index
evaluating 19 conditions and the purpose of the index is to predict
mortality in longitudinal studies.
When using these weighted measures, the population in which
the index is intended to be used and the outcome of interest should
ideally match those of the study in which it was developed.
However, this is rarely taken into consideration and the Charlson
index is the most prominent example of this situation as this
measure has been used in many other groups of patients and for a
variety of outcomes that differ from those of the original study. For
example, it has been used to predict future costs (M. Charlson,
Wells, Ullman, King, & Shmukler, 2014), to evaluate morbidity
burden in primary care and community settings (Huntley, Johnson,
Purdy, Valderas, & Salisbury, 2012), to predict long-term global
health and physical function in patients undergoing combined
radiotherapy for prostate cancer (Wahlgren, Levitt, Kowalski,
Nilsson, & Brandberg, 2011), and to study the association of
comorbidity and physical disability in patients with established
rheumatoid arthritis seen at an outpatient clinic (Radner, Smolen,
& Aletaha, 2010). Other indices have been developed to predict
different outcomes, and some of them have been intentionally
developed to predict more than one outcome. The outcomes that
weighted indices are intended to predict, as well as the associated
references, are included in Table 5 in the online supplemental
materials. Many of these indices have been developed in studies
involving hospital patients (M. E. Charlson et al., 1987; Crabtree,
Gray, Hildreth, O’Connell, & Brown, 2000; George et al., 2006;
Greenfield et al., 1993; Incalzi et al., 1997; Kaplan & Feinstein,
1974; H. Min et al., 2017; Rozzini et al., 2002; Sangha et al., 2003;
Shwartz, Iezzoni, Moskowitz, Ash, & Sawitz, 1996) and fewer
indices have involved participants from the general population
(McGee et al., 1996; Tooth, Hockey, Byles, & Dobson, 2008; Von
Korff, Wagner, & Saunders, 1992; Wei, Kawachi, Okereke, &
Mukamal, 2016), although one recent study involved a nationwide
population (Stanley & Sarfati, 2017).
Measuring Multimorbidity in a Study
In the preceding sections, we have presented a variety of exist-
ing measurements of multimorbidity, as well as highlighted dif-
ferences between these measures, in order to provide an introduc-
tion to the possibilities that are presented to a researcher who is
intending to measure multimorbidity in a study. To best orient a
study in which multimorbidity is assessed, one of the first ques-
tions that should be asked to inform the choice of a measure is:
 MEASUREMENT OF MULTIMORBIDITY
“Why is multimorbidity being measured in this study?” Some of
the possible answers to this question are discussed below.
To Measure Multimorbidity to Predict an Outcome
If multimorbidity will be measured to predict an outcome, then
the choice of measure should be a weighted index of multimor-
bidity. A number of outcomes that are predicted by different
multimorbidity indices were mentioned above. Indices that have
been developed in studies with similarities in setting, age group,
gender, method of collecting data, and outcome of interest with the
proposed study are preferred. However, it has been demonstrated
that indices developed to predict a specific outcome have also been
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
seen to predict additional outcomes. Examples of this are the
This document is copyrighted by the American Psychological Association or one of its allied publishers.
studies in which the Charlson index was used to predict outcomes
other than mortality (M. Charlson et al., 2014; Huntley et al., 2012;
Radner et al., 2010; Wahlgren et al., 2011). At the same time,
indices perform better in predicting the outcomes for which they
were developed and many single indices do not seem adequate to
predict multiple outcomes (Byles, D’Este, Parkinson, O’Connell,
& Treloar, 2005). If there are several outcomes of interest that will
be predicted in a given study, the use of more than one index of
multimorbidity should be considered.
The methods of data collection that have been used in the
existing literature to assess multimorbidity have included inter-
views, surveys or questionnaires, physical examinations, medical
chart reviews, and clinical or administrative databases. Many
weighted indices calculate scores with diagnoses confirmed with
medical records and therefore data collected by participant self-
report might not be appropriate for those indices. Many weighted
indices take into consideration mental health conditions in the
calculation of scores, but only limited diagnoses tend to be in-
cluded. The diagnoses that are most frequently considered have
been depression (Byles et al., 2005; Crabtree et al., 2000; Groll et
al., 2005; Newman, Boudreau, Naydeck, Fried, & Harris, 2008;
Sangha et al., 2003; Wei et al., 2016), dementia (M. E. Charlson et
al., 1987; George et al., 2006; Groll et al., 2005; Incalzi et al.,
1997; Radner et al., 2015; Stanley & Sarfati, 2017; Tooth et al.,
2008), anxiety (Crabtree et al., 2000; Radner et al., 2015; Stanley
& Sarfati, 2017; Tooth et al., 2008), and drug misuse (Fan et al.,
2002; Radner et al., 2015; Stanley & Sarfati, 2017).
To Measure Multimorbidity to Correct
for Confounding
The increasing prevalence of multimorbidity in any setting
(general population, primary care, medical centers, and special
groups) makes it a variable that can hardly be ignored as it may
affect the association with many important outcomes (including
polypharmacy, health care use, or self-management) and control-
ling for this factor can increase the internal validity of the study. If
multimorbidity is to be included as a measure in a study, the first
choice of measure might be a simple count from a specific list of
chronic conditions. This approach is often the easiest to apply to a
set of secondary data. The research team will then need to adopt an
operational definition of multimorbidity. The simplest operational
definition of multimorbidity has two components: the list of
chronic conditions considered and the minimal number of chronic
conditions to define multimorbidity. As mentioned, a list of 12
5
chronic conditions or more is considered to be appropriate to
measure multimorbidity, particularly in self-reported data from
patients or participants, so that the burden of multimorbidity will
not be underestimated (Fortin et al., 2012). With the choice of an
existing list of chronic conditions, or the development of a new one
while specifying the criteria for the selection of conditions, arises
the corresponding issue to consider: the number of chronic condi-
tions in the list. The use of a list previously published in studies
with similarities in setting, age group, gender, method of data
collection, and outcome of interest increases comparability of the
results for discussion.
Once a list of chronic conditions has been chosen, then the
cutoff used to determine the presence of multimorbidity should be
defined in the operational definition. Frequently used cutoffs are
two or more and three or more chronic conditions (Goodman,
Posner, Huang, Parekh, & Koh, 2013; Harrison, Britt, Miller, &
Henderson, 2014), but a cutoff of five or more has also been used
(Hillen et al., 2000). It is recommended to report the variable
distribution using the two prominent cutoff levels or to report the
variable as a continuous variable to allow for the calculation of
these cutoffs if necessary. It is possible that a multimorbidity
variable is used to adjust for confounding in a study, and consid-
ering disease severity might be particularly helpful. In that case, it
would then be necessary to use a weighted index assessing sever-
ity, such as the Comorbidity Symptom Scale (Crabtree et al.,
2000), the Disease Burden Morbidity Assessment (Bayliss, Ellis,
& Steiner, 2005) or the Complexity Score (Upshur, Wang,
Moineddin, Nie, & Tracy, 2012), and use the score of the index to
correct for confounding.
To Measure Multimorbidity to Explore Its Association
With Other Variables
Another situation could be that the measurement of multimor-
bidity is intended to test for associations with other variables or
outcomes. For example, an association can be explored between
the presence of multimorbidity and the subjects’ self-perceived
quality of life, quality of health care, and level of self-efficacy. In
this case, we may apply the same principles discussed in the
preceding section. Here again, the choice of a list of conditions or
a weighted index that evaluates disease severity depends on the
interest of the research team in considering this latter aspect in the
study. It was mentioned earlier that the development of many lists
for studying associations between variables or outcomes and mul-
timorbidity was driven by specific needs. In fact, the choice of a
multimorbidity measure for exploring associations could be facil-
itated by looking for a match between the objectives of the pro-
posed study and those of previous studies. It is possible that a
proposed study will be conducted to explore the association of
more than one variable or outcome with multimorbidity. As mea-
sures of multimorbidity have different associations with related
variables or outcomes, the use of more than one measure of
multimorbidity within the same study should be considered (For-
tin, Hudon, et al., 2005).
Conclusion
Multimorbidity is an important health phenomenon that has
increasingly attracted the interest of clinicians and researchers
 6 NICHOLSON, ALMIRALL, AND FORTIN
alike. It is reasonably simple to recognize multimorbidity in the
clinical context, but it is not that simple to assess and measure
multimorbidity for research purposes. After reading this review,
the reader should now have a general understanding of the existing
multimorbidity measurements in the current multimorbidity liter-
ature. This knowledge can then be used in future research studies
examining the phenomenon of multimorbidity.
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Received May 9, 2018
Revision received December 31, 2018
Accepted February 4, 2019 䡲