Understanding the High Prevalence of Low-Prevalence Chronic Disease Combinations: Databases and Methods for Research. The Context for Studying the Long Tail of Low-Prevalence Combinations


Clinical research has focused on single chronic disease conditions for decades. For many reasons, researchers have focused on understanding one medical condition at a time. Although especially true for clinical trials due to the need to reduce confounders and increase the strength of evidence, there is growing recognition of the limitations of this approach. As pointed out in a recent article by Tinetti and colleagues (2012) in the Journal of the American Medical Association, United States payment systems, service delivery, clinical decision making, and quality measurement have all been designed around single diseases. Until very recently, clinicians were paid according to individual diagnoses; in addition, many practitioners treat their patients according to guidelines and practices for a specific disease because guidelines for MCC do not exist in clinical practice. Paradoxically, however, most individuals with a chronic disease have more than one condition, and the group of individuals with MCC is growing.

Two thirds of healthcare spending is for multimorbid individuals over age 65 (Anderson, 2010). Boyd and colleagues (2005) examined the consequences of applying single disease guidelines to a hypothetical 79-year old woman with osteoporosis, osteoarthritis, type II diabetes mellitus, hypertension and chronic obstructive pulmonary disease, all of moderate severity. The results of these multiple guidelines for single conditions resulted in the patient being prescribed 12 medications requiring 19 doses per day, 14 non-pharmacological activities (e.g., nutrition), one-time education and rehabilitation interventions, and daily to biennial monitoring of chronic conditions requiring at least 2 to 4 primary care visits and 1 ophthalmology visit per year. In addition, there was potential for medication contraindications. The regime is not only impractical, it would result in potential risks, lack of care coordination, and burden on the patient and caregivers. In order for the United States health care system—particularly Medicare—to be successful, it must adapt to meet the needs of specific patients with MCC and their providers. To do so, accelerated knowledge and research about MCC is needed by policy-makers and healthcare providers.

There is extensive research on the most common chronic conditions in the Medicare population: hypertension, hyperlipidemia, ischemic heart disease, diabetes, arthritis, heart failure, depression, chronic kidney disease, osteoporosis, Alzheimer’s disease, etc.; and extensive research on these conditions in conjunction with a specific co-occurring chronic condition (for example hypertension and depression, or diabetes and chronic obstructive pulmonary disease); but very little research on low-prevalence MCC (CMS, 2011).


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