Incidence rate and determinants of multimorbidity in the community: A retrospective cohort study

Year 2025, Issue: Advanced Online Publication

Ali Köse , Eylül Tutal Altaş , Zeynep Sedef Varol , Buşra Tozduman , Gül Ergör , Alp Ergör

Abstract

Abstract
Objective: This study aims to estimate the incidence of multimorbidity between 2009 and 2023 and to identify its key determinants.
Methods: This retrospective cohort study was conducted using a sub-cohort derived from the 2009-Balçova’s Heart Study (2009-BAK), carried out in Balçova, İzmir. In the current study, the presence of multimorbidity was considered as the outcome variable, while age groups, gender, and education level were included as independent variables. The effect of independent variables on the dependent variable was analyzed using Cox regression analysis. The incidence rates of multimorbidity were calculated according to gender and age groups. Results: Among the participants, 66.7% were women and 8.2% were aged 70 years and older; hypertension was the most prevalent chronic condition, affecting 37.2% of the total sample. The incidence rate of multimorbidity was calculated as 27.3 per 1,000 person-years overall, with 27.6 observed in females and 41.4 among individuals aged 70 years and above. According to the results of multivariable Cox regression analysis, age was strongly associated with an increased risk of multimorbidity; individuals aged 70 and above had a 3.68-fold higher risk compared to those aged 30–39 (HR: 3.68, 95% CI: 2.63–5.16, p < 0.001). Conclusion: This study is the first cohort study conducted in our country on the epidemiology of multimorbidity. This study’s results highlight the importance of targeted preventive strategies for older populations to address the growing burden of multimorbidity.

Keywords: multimorbidity, incidence, cohort study

Keywords

multimorbidity , incidence , cohort study

Ethical Statement

This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Dokuz Eylül University Non-Interventional Research Ethics Committee under the decision dated October 26, 2022 (decision no: 2022/34-30) for the project titled “Evaluation of Serum Albumin, Creatinine, Uric Acid, Magnesium and CRP Levels in Relation to Type 2 Diabetes Mellitus, Cardiovascular Diseases, Dementia and Alzheimer’s Disease: The Balçova Heart (BAK) Prospective Cohort Study”. In addition, the thesis study based on this project was approved by the Dokuz Eylül University Non-Interventional Research Ethics Committee with the decision dated October 9, 2024 (decision no: 2024/33-06) under the title “Clusters and Determinants of Multimorbidity in the Community, and the Impact of Multimorbidity on Healthcare Utilization, Quality of Life, and Patient Activation”.

Supporting Institution

None.

Project Number

none.

Thanks

We would like to thank the Balçova’s Heart (BAK) Project team for their support in providing the study data.

References

• 1. Koné Pefoyo AJ, Bronskill SE, Gruneir A, et al. The increasing burden and complexity of multimorbidity. BMC Public Health. 2015;15:1-1.
• 2. Boyd CM, Fortin M. Future of multimorbidity research: How should understanding of multimorbidity inform health system design? Public Health Rev. 2010;32:451-474.
• 3. Fortin M, Bravo G, Hudon C, et al. Relationship between multimorbidity and health-related quality of life of patients in primary care. Qual Life Res. 2006;15(1):83-91.
• 4. Chowdhury SR, Das DC, Sunna TC, Beyene J, Hossain A. Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis. E ClinicalMedicine. 2023 Mar;57.
• 5. Geda NR, Janzen B, Pahwa P. Chronic disease multimorbidity among the Canadian population: prevalence and associated lifestyle factors. Arch Public Health. 2021;79(1):60.
• 6. Zhang L, Sun F, Li Y, Tang Z, Ma L. Multimorbidity in community-dwelling older adults in Beijing: prevalence and trends, 2004-2017. J Nutr Health Aging. 2021;25:116-119.
• 7. Ni W, Yuan X, Zhang Y, Zhang H, Zheng Y, Xu J. Sociodemographic and lifestyle determinants of multimorbidity among community-dwelling older adults: findings from 346,760 SHARE participants. BMC Geriatr. 2023;23(1):419.
• 8. Moreno-Juste A, Gimeno-Miguel A, Poblador-Plou B, et al. Multimorbidity, social determinants and intersectionality in chronic patients. Results from the EpiChron Cohort. J Glob Health. 2023;13:.
• 9. Dhungana RR, Karki KB, Bista B, Pandey AR, Dhimal M, Maskey MK. Prevalence, pattern and determinants of chronic disease multimorbidity in Nepal: secondary analysis of a national survey. BMJ Open. 2021;11(7):e047665.
• 10. Dhalwani NN, Zaccardi F, O’Donovan G, et al. Association between lifestyle factors and the incidence of multimorbidity in an older English population. J Gerontol A Biol Sci Med Sci. 2017;72(4):528-534.
• 11. 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(582):e12-e21.
• 12. Palladino R, Tayu Lee J, Ashworth M, Triassi M, Millett C. Associations between multimorbidity, healthcare utilisation and health status: evidence from 16 European countries. Age Ageing. 2016;45(3):431-435.
• 13. Garin N, Olaya B, Moneta MV, Miret M, Lobo A, Ayuso-Mateos JL, Haro JM. Impact of multimorbidity on disability and quality of life in the Spanish older population. PLoS One. 2014;9(11):e111498.
• 14. Nunes BP, Flores TR, Mielke GI, Thume E, Facchini LA. Multimorbidity and mortality in older adults: a systematic review and meta-analysis. Arch Gerontol Geriatr. 2016;67:130-138.
• 15. Akturan S, Karahan Ö, Akman M. The prevalence of multimorbidity among adults aged 40 years and above in primary care setting: a cross-sectional study. Konuralp Medical Journal. 2021;13(3):563-9.
• 16. Altaş ET, Varol ZS, Tozduman B, Köse A, Tuncel EP, Gürsoy Doruk Ö, Uysal S, Ergör G. İzmir İli Balçova İlçesinde Bulaşıcı Olmayan Hastalıklar İnsidansı: 15 Yıllık Kohort Çalışması [sözlü bildiri]. 8. Uluslararası ve 26. Ulusal Halk Sağlığı Kongresi; 5-7 Aralık 2024; Ankara, Türkiye.
• 17. Altaş ET, Varol ZS, Tozduman B, Köse A, Tuncel EP, Gürsoy Doruk Ö, Uysal S, Ergör G. Erken Dönem Biyokimyasal Ölçümlerin Tip 2 Diyabet, Kardiyovasküler Hastalıklar Ve Demans İle İlişkisi: 15 Yıllık Kohort Sonuçları [sözlü bildiri]. 8. Uluslararası ve 26. Ulusal Halk Sağlığı Kongresi; 5-7 Aralık 2024; Ankara, Türkiye.
• 18. Ergör G, Soysal A, Sözmen K, Ünal B, Uçku R, Kılıç B, Günay T, Ergör A, Demiral Y, Saatlı G, Meseri R. Balcova heart study: rationale and methodology of the Turkish cohort. International journal of public health. 2012;57(3):535-542.
• 19. Kopp W. Aging and “age-related” diseases-what is the relation?. Aging and disease. 2024 Jun 28;16(3):1316. 20. TÜİK Kurumsal [Internet]. [cited 2025 Sep 21]. Available from: https://data.tuik.gov.tr/Bulten/Index?p=Elderly-Statistics-2024-54079
• 21. Lee TW, Chung J, Song K, Kim E. Incidence and predictors of multimorbidity among older adults in Korea: a 10-year cohort study. BMC Geriatr. 2022;22(1):565.
• 22. 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.
• 23. Aminisani N, Stephens C, Allen J, Alpass F, Shamshirgaran SM. Socio-demographic and lifestyle factors associated with multimorbidity in New Zealand. Epidemiol Health. 2020;42:-.
• 24. Mounce LT, Campbell JL, Henley WE, Arreal MC, Porter I, Valderas JM. Predicting incident multimorbidity. Ann Fam Med. 2018;16(4):322-329.
• 25. 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;12:1-8.
• 26. Atak M, Sezerol MA, Altaş ZM. Chronic Disease Management in Primary Care: A Cross-Sectional Study in Türkiye. Phoenix Med J. 2023;5(3):211-216.