BMC Medicine | |
The impact of multimorbidity on adult physical and mental health in low- and middle-income countries: what does the study on global ageing and adult health (SAGE) reveal? | |
Paul Kowal8  Somnath Chatterji2  Nirmala Naidoo2  James Josh Snodgrass3  Melissa A. Liebert3  Sube Banerjee1,11  Gillian Ice9  Sanghamitra Pati4  Sara Afshar5  Aarón Salinas Rodríguez1  Betty Manrique Espinoza1  Tamara Maximova6  Yanfei Guo1,10  Fan Wu1,10  Alfred Edwin Yawson7  Richard Berko Biritwum7  Kshipra Jain1,12  Uttamacharya Uttamacharya1,12  Perianayagam Arokiasamy1,12  | |
[1] National Institute of Public Health (INSP), Centre for Evaluation Research and Surveys, Cuernavaca, Morelos, Mexico;World Health Organization Study on global AGEing and adult health (SAGE), Geneva, Switzerland;University of Oregon, Department of Anthropology, Eugene, OR, USA;Indian Institute of Public Health, Bhubaneswar, Public Health Foundation of India, Bhubaneswar, Odisha, India;Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton SO17 1BJ, UK;Russian Academy of Medical Sciences (RAMS), Moscow, Russian Federation;Department of Community Health, University of Ghana, Accra, Ghana;University of Newcastle Priority Research Centre for Gender, Health and Ageing, Newcastle, NSW, Australia;Ohio University, Department of Social Medicine and Director of Global Health, Athens, OH, USA;Shanghai Municipal Center for Disease Control and Prevention (CDC), Shanghai, China;Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton, UK;International Institute for Population Sciences, Mumbai, India | |
关键词: Quality of life; Non-communicable diseases; Multimorbidity; Mental health; Low- and middle-income countries; Activities of daily living; | |
Others : 1222068 DOI : 10.1186/s12916-015-0402-8 |
|
received in 2015-04-16, accepted in 2015-06-17, 发布年份 2015 | |
【 摘 要 】
Background
Chronic diseases contribute a large share of disease burden in low- and middle-income countries (LMICs). Chronic diseases have a tendency to occur simultaneously and where there are two or more such conditions, this is termed as ‘multimorbidity’. Multimorbidity is associated with adverse health outcomes, but limited research has been undertaken in LMICs. Therefore, this study examines the prevalence and correlates of multimorbidity as well as the associations between multimorbidity and self-rated health, activities of daily living (ADLs), quality of life, and depression across six LMICs.
Methods
Data was obtained from the WHO’s Study on global AGEing and adult health (SAGE) Wave-1 (2007/10). This was a cross-sectional population based survey performed in LMICs, namely China, Ghana, India, Mexico, Russia, and South Africa, including 42,236 adults aged 18 years and older. Multimorbidity was measured as the simultaneous presence of two or more of eight chronic conditions including angina pectoris, arthritis, asthma, chronic lung disease, diabetes mellitus, hypertension, stroke, and vision impairment. Associations with four health outcomes were examined, namely ADL limitation, self-rated health, depression, and a quality of life index. Random-intercept multilevel regression models were used on pooled data from the six countries.
Results
The prevalence of morbidity and multimorbidity was 54.2 % and 21.9 %, respectively, in the pooled sample of six countries. Russia had the highest prevalence of multimorbidity (34.7 %) whereas China had the lowest (20.3 %). The likelihood of multimorbidity was higher in older age groups and was lower in those with higher socioeconomic status. In the pooled sample, the prevalence of 1+ ADL limitation was 14 %, depression 5.7 %, self-rated poor health 11.6 %, and mean quality of life score was 54.4. Substantial cross-country variations were seen in the four health outcome measures. The prevalence of 1+ ADL limitation, poor self-rated health, and depression increased whereas quality of life declined markedly with an increase in number of diseases.
Conclusions
Findings highlight the challenge of multimorbidity in LMICs, particularly among the lower socioeconomic groups, and the pressing need for reorientation of health care resources considering the distribution of multimorbidity and its adverse effect on health outcomes.
【 授权许可】
2015 Arokiasamy et al.
【 预 览 】
Files | Size | Format | View |
---|---|---|---|
20150805021242954.pdf | 1237KB | download | |
Fig. 2. | 57KB | Image | download |
Fig. 1. | 31KB | Image | download |
【 图 表 】
Fig. 1.
Fig. 2.
【 参考文献 】
- [1]World Population Ageing 2013. ST/ESA/SER.A/348. United Nations, New York; 2013.
- [2]Quigley MA. Commentary: shifting burden of disease–epidemiological transition in India. Int J Epidemiol. 2006; 35:1530-1.
- [3]Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet. 2007; 370:1929-38.
- [4]Miranda JJ, Kinra S, Casas JP, Davey Smith G, Ebrahim S. Non-communicable diseases in low- and middle-income countries: context, determinants and health policy. Tropical Med Int Health. 2008; 13:1225-34.
- [5]Ebrahim S, Pearce N, Smeeth L, Casas JP, Jaffar S, Piot P. Tackling non-communicable diseases in low- and middle-income countries: is the evidence from high-income countries all we need? PLoS Med. 2013; 10: Article ID e1001377
- [6]Smith SM, O’Dowd T. Chronic diseases: what happens when they come in multiples? Br J Gen Pract. 2007; 57:268-70.
- [7]Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M. Multimorbidity’s many challenges. BMJ. 2007; 334:1016-7.
- [8]Prados-Torres A, Poblador-Plou B, Calderon-Larranaga A, Gimeno-Feliu LA, Gonzalez-Rubio F, Poncel-Falco A et al.. Multimorbidity patterns in primary care: interactions among chronic diseases using factor analysis. PLoS One. 2012; 7: Article ID e32190
- [9]van den Akker M, Buntinx F, Metsemakers JF, Roos S, Knottnerus JA. Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol. 1998; 51:367-75.
- [10]Gijsen R, Hoeymans N, Schellevis FG, Ruwaard D, Satariano WA, van den Bos GA. Causes and consequences of comorbidity: a review. J Clin Epidemiol. 2001; 54:661-74.
- [11]Walker AE. Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia. Chronic Illn. 2007; 3:202-18.
- [12]Khanam MA, Streatfield PK, Kabir ZN, Qiu C, Cornelius C, Wahlin A. Prevalence and patterns of multimorbidity among elderly people in rural Bangladesh: a cross-sectional study. J Health Popul Nutr. 2011; 29:406-14.
- [13]Salisbury C, Johnson L, Purdy S, Valderas JM, Montgomery AA. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2011; 61:e12-21.
- [14]Salive ME. Multimorbidity in older adults. Epidemiol Rev. 2013; 35:75-83.
- [15]Mercer SW, Smith SM, Wyke S, O’Dowd T, Watt GC. Multimorbidity in primary care: developing the research agenda. Fam Pract. 2009; 26:79-80.
- [16]Taylor AW, Price K, Gill TK, Adams R, Pilkington R, Carrangis N et al.. Multimorbidity – not just an older person’s issue. Results from an Australian biomedical study. BMC Public Health. 2010; 10:718. BioMed Central Full Text
- [17]Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012; 380:37-43.
- [18]Agborsangaya CB, Lau D, Lahtinen M, Cooke T, Johnson JA. Multimorbidity prevalence and patterns across socioeconomic determinants: a cross-sectional survey. BMC Public Health. 2012; 12:201. BioMed Central Full Text
- [19]Pati S, Agrawal S, Swain S, Lee JT, Vellakkal S, Hussain MA et al.. Non-communicable disease multimorbidity and associated health care utilization and expenditures in India: cross-sectional study. BMC Health Serv Res. 2014; 14:451. BioMed Central Full Text
- [20]Uijen AA, van de Lisdonk EH. Multimorbidity in primary care: prevalence and trend over the last 20 years. Eur J Gen Pract. 2008; 14:28-32.
- [21]Schafer I, Hansen H, Schon G, Hofels S, Altiner A, Dahlhaus A et al.. The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. First results from the multicare cohort study. BMC Health Serv Res. 2012; 12:89. BioMed Central Full Text
- [22]Alaba O, Chola L. The social determinants of multimorbidity in South Africa. Int J Equity Health. 2013; 12:63. BioMed Central Full Text
- [23]Chandola T, Ferrie J, Sacker A, Marmot M. Social inequalities in self-reported health in early old age: follow-up of prospective cohort study. BMJ. 2007; 334:990.
- [24]Mercer SW, Watt GC. The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland. Ann Fam Med. 2007; 5:503-10.
- [25]Boutayeb A, Boutayeb S, Boutayeb W. Multi-morbidity of non communicable diseases and equity in WHO Eastern Mediterranean countries. Int J Equity Health. 2013; 12:60. BioMed Central Full Text
- [26]Fried LP, Bandeen-Roche K, Kasper JD, Guralnik JM. Association of comorbidity with disability in older women: the Women’s Health and Aging Study. J Clin Epidemiol. 1999; 52:27-37.
- [27]Kadam UT, Croft PR. Clinical multimorbidity and physical function in older adults: a record and health status linkage study in general practice. Fam Pract. 2007; 24:412-9.
- [28]Fortin M, Lapointe L, Hudon C, Vanasse A, Ntetu AL, Maltais D. Multimorbidity and quality of life in primary care: a systematic review. Health Qual Life Outcomes. 2004; 2:51. BioMed Central Full Text
- [29]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; 66:380-6.
- [30]Hoeymans N, Feskens EJ, Kromhout D, van den Bos GA. The contribution of chronic conditions and disabilities to poor self-rated health in elderly men. J Gerontol Ser A Biol Sci Med Sci. 1999; 54:M501-6.
- [31]Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002; 162:2269-76.
- [32]Verbrugge LM, Lepkowski JM, Imanaka Y. Comorbidity and its impact on disability. Milbank Q. 1989; 67:450-84.
- [33]Parekh AK, Barton MB. The challenge of multiple comorbidity for the US health care system. JAMA. 2010; 303:1303-4.
- [34]Tu HT. Rising health costs, medical debt and chronic conditions. Issue Brief Cent Stud Health Syst Change. 2004; 88:1-5.
- [35]Lehnert T, Heider D, Leicht H, Heinrich S, Corrieri S, Luppa M et al.. Review: health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev. 2011; 68:387-420.
- [36]Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A et al.. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011; 10:430-9.
- [37]Househam KC. Africa’s burden of disease: the University of Cape Town sub-Saharan Africa Centre for Chronic Disease. S Afr Med J. 2010; 100:94-5.
- [38]Zeba AN, Delisle HF, Renier G, Savadogo B, Baya B. The double burden of malnutrition and cardiometabolic risk widens the gender and socio-economic health gap: a study among adults in Burkina Faso (West Africa). Public Health Nutr. 2012; 15:2210-9.
- [39]Nugent R. Chronic diseases: a growing problem in developing countries. Diabetes Voice. 2008; 53:17-20.
- [40]Mendis S. The policy agenda for prevention and control of non-communicable diseases. Br Med Bull. 2010; 96:23-43.
- [41]He W, Muenchrath MN, Kowal P. Shades of gray: a cross-country study of health and well-being of the older populations in SAGE countries, 2007–2010. U.S. Government Printing Office, Washington DC; 2012.
- [42]Kowal P, Chatterji S, Naidoo N, Biritwum R, Fan W, Lopez Ridaura R et al.. Data resource profile: the World Health Organization Study on global AGEing and adult health (SAGE). Int J Epidemiol. 2012; 41:1639-49.
- [43]Naidoo N. WHO Study on global AGEING and adult health (SAGE) Waves 0 and 1 - Sampling information for China, Ghana, India, Mexico, Russia, and South Africa. SAGE Working Paper No 5. World Health Organization, Geneva; 2012.
- [44]Whitworth JA. World Health Organization/International Society of Hypertension statement on management of hypertension. J Hypertens. 2003; 21:1983-92.
- [45]Virgili G, Acosta R, Grover LL, Bentley SA, Giacomelli G. Reading aids for adults with low vision. Cochrane Database Syst Rev. 2013; 10: Article ID CD003303
- [46]International Council of Ophthalmology. Visual acuity measurement standard. Visual Functions Committee. San Fransisco, CA: ICO; 1984.
- [47]Ustun TB, Chatterji S, Kostanjsek N, Rehm J, Kennedy C, Epping-Jordan J et al.. Developing the World Health Organization Disability Assessment Schedule 2.0. Bull World Health Organ. 2010; 88:815-23.
- [48]Schmidt S, Muhlan H, Power M. The EUROHIS-QOL 8-item index: psychometric results of a cross-cultural field study. Eur J Pub Health. 2006; 16:420-8.
- [49]Kessler RC, Ustun TB. The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res. 2004; 13:93-121.
- [50]Ayuso-Mateos JL, Nuevo R, Naidoo N, Chatterji S. From depressive symptoms to depressive disorders: the relevance of thresholds. Br J Psychiatry J Ment Sci. 2010; 196:365-71.
- [51]Ferguson BD, Tandon A, Gakidou E, Murray CJL. Estimating permanent income using indicator variables. Health systems performance assessment: debates, methods and empiricism. Murray CJL, Evans DB, editors. World Health Organization, Geneva; 2003.
- [52]Sobal J, Stunkard AJ. Socioeconomic status and obesity: a review of the literature. Psychol Bull. 1989; 105:260-75.
- [53]Smith KV, Goldman N. Socioeconomic differences in health among older adults in Mexico. Soc Sci Med. 2007; 65:1372-85.
- [54]Dinsa GD, Goryakin Y, Fumagalli E, Suhrcke M. Obesity and socioeconomic status in developing countries: a systematic review. Obes Rev. 2012; 13:1067-79.
- [55]Aitsi-Selmi A, Bell R, Shipley MJ, Marmot MG. Education modifies the association of wealth with obesity in women in middle-income but not low-income countries: an interaction study using seven national datasets, 2005–2010. PLoS One. 2014; 9: Article ID e90403
- [56]Hosseinpoor AR, Bergen N, Kunst A, Harper S, Guthold R, Rekve D et al.. Socioeconomic inequalities in risk factors for non communicable diseases in low-income and middle-income countries: results from the World Health Survey. BMC Public Health. 2012; 12:912. BioMed Central Full Text
- [57]Blakely T, Hales S, Kieft C, Wilson N, Woodward A. The global distribution of risk factors by poverty level. Bull World Health Organ. 2005; 83:118-26.
- [58]Kirchberger I, Meisinger C, Heier M, Zimmermann AK, Thorand B, Autenrieth CS et al.. Patterns of multimorbidity in the aged population. Results from the KORA-Age study. PLoS One. 2012; 7: Article ID e30556
- [59]Schram MT, Frijters D, van de Lisdonk EH, Ploemacher J, de Craen AJ, de Waal MW et al.. Setting and registry characteristics affect the prevalence and nature of multimorbidity in the elderly. J Clin Epidemiol. 2008; 61:1104-12.
- [60]Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S et al.. The global economic burden of non-communicable diseases. World Economic Forum, Geneva; 2011.
- [61]Dey S, Nambiar D, Lakshmi JK, Sheikh K, Reddy KS. Health of the elderly in India: Challenges of access and affordability. In: Aging in Asia: Findings from new and emerging data initiatives. Smith P, Majmundar M, editors. National Academies Press, Washington, DC; 2012: p.371-86.
- [62]Williams R, Krakauer R. The challenge of non-communicable diseases and geriatric conditions. In: Global population ageing: peril or promise? Geneva: World Economic Forum; 2011.
- [63]Morbidity, Health Care and the Condition of the Aged. National Sample Survey, 60th Round. Report no. 507 (60/25.0/1). Ministry of Statistics and Programme Implementation, Government of India, New Delhi; 2006.
- [64]Tang S, Ehiri J, Long Q. China’s biggest, most neglected health challenge: non-communicable diseases. Infect Dis Poverty. 2013; 2:7. BioMed Central Full Text
- [65]Yang G, Kong L, Zhao W, Wan X, Zhai Y, Chen LC et al.. Emergence of chronic non-communicable diseases in China. Lancet. 2008; 372:1697-705.
- [66]Bloom DE, Cafiero ET, McGovern ME, Prettner K, Stanciole A, Weiss J, et al. The economic impact of non-communicable disease in China and India: estimates, projections, and comparisons. PGDA working paper 2013. http://cdn1. sph.harvard.edu/wp-content/uploads/sites/1288/2013/10/PGDA_WP_107.pdf webcite
- [67]Gonzalez-Pier E, Gutierrez-Delgado C, Stevens G, Barraza-Llorens M, Porras-Condey R, Carvalho N et al.. Priority setting for health interventions in Mexico’s System of Social Protection in Health. Lancet. 2006; 368:1608-18.
- [68]Lozano R, Gomez-Dantes H, Garrido-Latorre F, Jimenez-Corona A, Campuzano-Rincon JC, Franco-Marina F et al.. Burden of disease, injuries, risk factors and challenges for the health system in Mexico. Publica de Mexico. 2013; 55:580-94.
- [69]Bosu WK. A comprehensive review of the policy and programmatic response to chronic non-communicable disease in Ghana. Ghana Med J. 2012; 46:69-78.
- [70]Chenet L, Leon D, McKee M, Vassin S. Deaths from alcohol and violence in Moscow: socio-economic determinants. Eur J Popul. 1998; 14:19-37.
- [71]Leon DA, Shkolnikov VM. Social stress and the Russian mortality crisis. JAMA. 1998; 279:790-1.
- [72]Notzon FC, Komarov YM, Ermakov SP, Sempos CT, Marks JS, Sempos EV. Causes of declining life expectancy in Russia. JAMA. 1998; 279:793-800.
- [73]Cockerham WC. Healthy lifestyles in Russia. Soc Sci Med. 2000; 51:1313-24.
- [74]Joubert J, Bradshaw D. Population ageing and health challenges in South Africa. Chronic diseases of lifestyle in South Africa since 1995–2005. Fourie J, Steyn K, Temple NJ, Council SAMR, editors. Medical Research Council, Tygerberg; 2006.
- [75]GBD 2010 Profile: South Africa. IHME, Seattle; 2013.
- [76]Fortin M, Dubois MF, Hudon C, Soubhi H, Almirall J. Multimorbidity and quality of life: a closer look. Health Qual Life Outcomes. 2007; 5:52. BioMed Central Full Text
- [77]Gunn JM, Ayton DR, Densley K, Pallant JF, Chondros P, Herrman HE et al.. The association between chronic illness, multimorbidity and depressive symptoms in an Australian primary care cohort. Soc Psychiatry Psychiatr Epidemiol. 2012; 47:175-84.
- [78]Lawson KD, Mercer SW, Wyke S, Grieve E, Guthrie B, Watt GC et al.. Double trouble: the impact of multimorbidity and deprivation on preference-weighted health related quality of life a cross sectional analysis of the Scottish Health Survey. Int J Equity Health. 2013; 12:67. BioMed Central Full Text
- [79]Smith DJ, Court H, McLean G, Martin D, Langan Martin J, Guthrie B et al.. Depression and multimorbidity: a cross-sectional study of 1,751,841 patients in primary care. J Clin Psychiatry. 2014; 75:1202-8.
- [80]Stenholm S, Westerlund H, Head J, Hyde M, Kawachi I, Pentti J et al.. Comorbidity and functional trajectories from midlife to old age: The Health and Retirement Study. J Gerontol Ser A Biol Sci Med Sci. 2015; 70:332-8.
- [81]Hunger M, Thorand B, Schunk M, Doring A, Menn P, Peters A et al.. Multimorbidity and health-related quality of life in the older population: results from the German KORA-age study. Health Qual Life Outcomes. 2011; 9:53. BioMed Central Full Text
- [82]Gilson BS, Gilson JS, Bergner M, Bobbit RA, Kressel S, Pollard WE et al.. The sickness impact profile. Development of an outcome measure of health care. Am J Public Health. 1975; 65:1304-10.
- [83]Wang HH, Wang JJ, Wong SY, Wong MC, Li FJ, Wang PX et al.. Epidemiology of multimorbidity in China and implications for the healthcare system: cross-sectional survey among 162,464 community household residents in southern China. BMC Med. 2014; 12:188. BioMed Central Full Text
- [84]Wang HHX, Wang JJ, Lawson KD, Wong SYS, Wong MCS, Li FJ et al.. Relationships of multimorbidity and income with hospital admissions in 3 health care systems. Ann Fam Med. 2015; 13:164-7.
- [85]Payne RA, Abel GA, Guthrie B, Mercer SW. The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. CMAJ. 2013; 185:E221-8.
- [86]Guthrie B, Saultz JW, Freeman GK, Haggerty JL. Continuity of care matters. BMJ. 2008; 337:a867.
- [87]van Weel C, Schellevis FG. Comorbidity and guidelines: conflicting interests. Lancet. 2006; 367:550-1.
- [88]Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005; 294:716-24.
- [89]WHO. The World Health Report 2008: primary healthcare, now more than ever. Geneva, Switzerland: World Health Organization; 2008.
- [90]Banerjee S. Multimorbidity—older adults need health care that can count past one. Lancet. 2015; 385:587-9.
- [91]WHO. WHO strategy on people-centered and integrated health services. Geneva: World Health Organization; 2014.
- [92]Allotey P, Davey T, Reidpath DD. NCDs in low- and middle-income countries – assessing the capacity of health systems to respond to population needs. BMC Public Health. 2014; 14:S1. BioMed Central Full Text
- [93]Hosseinpoor AR, Bergen N, Mendis S, Harper S, Kunst A, Chatterji S. Socioeconomic inequality in the prevalence of noncommunicable diseases in low- and middle-income countries: results from the World Health Survey. BMC Public Health. 2012; 12:474. BioMed Central Full Text
- [94]Basu S, King AC. Disability and chronic disease among older adults in India: detecting vulnerable populations through the WHO SAGE Study. Am J Epidemiol. 2013; 178:1620-8.
- [95]Levesque JF, Mukherjee S, Grimard D, Boivin A, Mishra S. Measuring the prevalence of chronic diseases using population surveys by pooling self-reported symptoms, diagnosis and treatments: results from the World Health Survey of 2003 for South Asia. Int J Public Health. 2013; 58:435-47.
- [96]Vellakkal S, Millett C, Basu S, Khan Z, Aitsi-Selmi A, Stuckler D et al.. Are estimates of socioeconomic inequalities in chronic disease artefactually narrowed by self-reported measures of prevalence in low-income and middle-income countries? Findings from the WHO-SAGE survey. J Epidemiol Community Health. 2015; 69:218-25.
- [97]Diederichs C, Berger K, Bartels DB. The measurement of multiple chronic diseases–a systematic review on existing multimorbidity indices. J Gerontol A: Biol Med Sci. 2011; 66:301-11.
- [98]Violan C, Foguet-Boreu Q, Flores-Mateo G, Salisbury C, Blom J, Freitag M et al.. Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies. PLoS One. 2014; 9: Article ID e102149