Selected Publications on Multiple Chronic Conditions, 2002-2013

This bibliography lists selected publications on the topic of multiple chronic conditions compiled by the AHRQ Multiple Chronic Conditions (MCC) Research Network Technical Assistance Center. The publications included in this list are primarily from 2010 through 2013, the years during which the AHRQ MCC Research Network was in operation; however, some seminal literature from years prior to 2010 is also included. The bibliography was compiled via a review of published articles using the keywords “multiple chronic conditions” and “complex patients,” as well as through nomination by AHRQ MCC Research Network investigators. Articles were selected if they related to the work of one or more network research teams or if the topic had wide applicability to MCC Research Network, based on the reviewers’ judgment.
  1. Anderson G. Chronic Care: Making the Case for Ongoing Care [Robert Wood Johnson Foundation web site]. February, 2010. Available at: Accessed August, 31, 2013.
  2. Arora S, Kalishman S, Dion D, et al. Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care. Health Aff (Millwood). Jun 2011;30(6):1176–1184.
  3. Ashman JJ and Beresovsky V. Multiple chronic conditions among US adults who visited physician offices: data from the National Ambulatory Medical Care Survey, 2009. Prev Chronic Dis. Apr 2013;10:E64.
  4. Bao Y, Casalino LP, Pincus HA. Behavioral health and health care reform models: patient-centered medical home, health home, and accountable care organization. J Behav Health Serv Res. 2012.
  5. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. Jul 7 2012;380(9836):37–43.
  6. Baron RJ. New pathways for primary care: an update on primary care programs from the innovation center at CMS. Ann Fam Med. Mar-Apr 2012;10(2):152–155.
  7. Basu J. Medicare managed care and primary care quality: examining racial/ethnic effects across states. Health Care Manag Sci. Mar 2012;15(1):15–28.
  8. Bayliss EA. Simplifying care for complex patients. Ann Fam Med. Jan–Feb 2012;10(1):3-5.
  9. Bayliss EA, Ellis JL, Shoup JA, et al. Association of patient-centered outcomes with patient-reported and ICD-9-based morbidity measures. Ann Fam Med. Mar–Apr 2012;10(2):126–133.
  10. Berry-Millett R, Bodenheimer TS. Care management of patients with complex health care needs. Synth Proj Res Synth Rep. Dec 2009(19).
  11. Boult C, Reider L, Leff B, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. Mar 14 2011;171(5):460–466.
  12. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. Aug 10 2005;294(6):716–724.
  13. Boyd CM, Vollenweider D, Puhan MA. Informing evidence-based decision-making for patients with comorbidity: availability of necessary information in clinical trials for chronic diseases. PLoS One. 2012;7(8):e41601.
  14. Brown R, Peikes D, Peterson G. Features of successful care coordination programs [PowerPoint Slides on Robert Wood Johnson Foundation web site]. December 16, 2009. Available at: Accessed August 31, 2013.
  15. Carlin CS, Christianson JB, Keenan P, et al. Chronic illness and patient satisfaction. Health Serv Res. Dec 2012;47(6):2250–2272.
  16. Caughey GE, Preiss AK, Vitry AI, et al. Comorbid diabetes and COPD: impact of corticosteroid use on diabetes complications. Diabetes Care. Jun 4 2013.
  17. Centers for Medicare & Medicaid Services. Chronic Conditions Among Medicare Beneficiaries – Chartbook, 2012 Edition. Available at: Accessed August 31, 2013.
  18. Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. Mar 2011;127(3):529–538.
  19. Dalal AA, Shah M, Lunacsek O, et al. Clinical and economic burden of patients diagnosed with COPD with comorbid cardiovascular disease. Respir Med. Oct 2011;105(10):1516–1522.
  20. Diederichs CP, Wellmann J, Bartels DB, et al. How to weight chronic diseases in multimorbidity indices? Development of a new method on the basis of individual data from five population-based studies. J Clin Epidemiol. Jun 2012;65(6):679–685.
  21. Diez Roux AV. Complex systems thinking and current impasses in health disparities research. Am J Public Health. Sep 2011;101(9):1627–1634.
  22. Druss BG, von Esenwein SA, Compton MT, et al. Budget impact and sustainability of medical care management for persons with serious mental illnesses. Am J Psychiatry. Nov 2011;168(11):1171–1178.
  23. Findley P, Shen C, Sambamoorthi U. Multimorbidity and persistent depression among veterans with diabetes, heart disease, and hypertension. Health Soc Work. May 2011;36(2):109–119.
  24. Ford ES, Croft JB, Posner SF, et al. Co-occurrence of leading lifestyle-related chronic conditions among adults in the United States, 2002-2009. Prev Chronic Dis. Apr 2013;10:E60.
  25. Formiga F, Ferrer A, Sanz H, et al. Patterns of comorbidity and multimorbidity in the oldest old: the Octabaix study. Eur J Intern Med. Jan 2013;24(1):40–44.
  26. Frasure-Smith N and Lesperance F. Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease. Arch Gen Psychiatry. Jan 2008;65(1):62–71.
  27. Freid VM, Bernstein AB, Bush MA. Multiple chronic conditions among adults aged 45 and over: trends over the past 10 years. NCHS Data Brief. Jul 2012(100):1-8.
  28. Fricton J, Rindal DB, Rush W, et al. The effect of electronic health records on the use of clinical care guidelines for patients with medically complex conditions. J Am Dent Assoc. Oct 2011;142(10):1133–1142.
  29. Fried TR, Tinetti ME, Iannone L. Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med. Jan 10 2011;171(1):75–80.
  30. Goodman RA, Parekh AK, Koh HK. Toward a more cogent approach to the challenges of multimorbidity. Ann Fam Med. Mar-Apr 2012;10(2):100–101.
  31. Goodman RA, Posner SF, Huang ES, et al. Defining and measuring chronic conditions: imperatives for research, policy, program , and practice. Prev Chronic Dis. Apr 2013;10:E66.
  32. Gorina Y and Kramarow EA. Identifying chronic conditions in Medicare claims data: evaluating the Chronic Condition Data Warehouse algorithm. Health Serv Res. Oct 2011;46(5):1610–1627.
  33. Grant RW, Ashburner JM, Hong CS, et al. Defining patient complexity from the primary care physician's perspective: a cohort study. Ann Intern Med. Dec 20 2011;155(12):797–804.
  34. Haggerty JL. Ordering the chaos for patients with multimorbidity. BMJ. 2012;345:e5915.
  35. Haverhals LM, Lee CA, Siek KA, et al. Older adults with multi-morbidity: medication management processes and design implications for personal health applications. J Med Internet Res. 2011;13(2):e44.
  36. Huber M, Knottnerus JA, Green L, et al. How should we define health? BMJ. 2011;343:d4163.
  37. Hughes LD, McMurdo ME, Guthrie B. Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing. Jan 2013;42(1):62–69.
  38. Hung WW, Egol KA, Zuckerman JD, et al. Hip fracture management: tailoring care for the older patient. JAMA. May 23 2012;307(20):2185–2194.
  39. Huntley AL, Johnson R, Purdy S, et al. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med. Mar–Apr 2012;10(2):134–141.
  40. Institute of Medicine. Living Well with Chronic Illness: A Call for Public Health Action. January 31, 2012. Available at: Accessed August 31, 2013.
  41. Kamerow D. How can we treat multiple chronic conditions? BMJ. 2012;344:e1487.
  42. Katon W, Lyles CR, Parker MM, et al. Association of depression with increased risk of dementia in patients with type 2 diabetes: the Diabetes and Aging Study. Arch Gen Psychiatry. Apr 2012;69(4):410–417.
  43. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care. Dec 2012;35(12):2650–2664.
  44. Koroukian SM, Bakaki PM, Schluchter MD, et al. Treatment and survival patterns in relation to multimorbidity in patients with locoregional breast and colorectal cancer. J Geriatr Oncol. Jul 2011;2(3):200–208.
  45. Kroenke K, Wu J, Bair MJ, et al. Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. J Pain. Sep 2011;12(9):964–973.
  46. Kronick RG, Bella M, Gilmer TP, et al. The Faces of Medicaid II: Recognizing the Care Needs of People with Multiple Chronic Conditions [Center for Health Care Strategies, Inc. web site]. October, 2007. Available at: Accessed August 31, 2013.
  47. Laiteerapong N, Iveniuk J, John PM, et al. Classification of older adults who have diabetes by comorbid conditions, United States, 2005-2006. Prev Chronic Dis. 2012;9:E100.
  48. Langan J, Mercer SW, Smith DJ. Multimorbidity and mental health: can psychiatry rise to the challenge? Br J Psychiatry. Jun 2013;202:391–393.
  49. Lehnert T, Heider D, Leicht H, et al. Review: health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev. Aug 2011;68(4):387–420.
  50. Lin EH, Von Korff M, Ciechanowski P, et al. Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: a randomized controlled trial. Ann Fam Med. Jan–Feb 2012;10(1):6–14.
  51. Lochner KA and Cox CS. Prevalence of multiple chronic conditions among Medicare beneficiaries, United States, 2010. Prev Chronic Dis. Apr 2013;10:E61.
  52. Loeb DF, Bayliss EA, Binswanger IA, et al. Primary care physician perceptions on caring for complex patients with medical and mental illness. J Gen Intern Med. Aug 2012;27(8):945–952.
  53. Machlin SR and Soni AS. Health care expenditures for adults with multiple treated chronic conditions: estimates from the Medical Expenditure Panel Survey, 2009. Prev Chronic Dis. Apr 2013;10:E63.
  54. McDaid O, Hanly MJ, Richardson K, et al. 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).
  55. Morris RL, Sanders C, Kennedy AP, et al. Shifting priorities in multimorbidity: a longitudinal qualitative study of patient's prioritization of multiple conditions. Chronic Illn. Jun 2011;7(2):147–161.
  56.  Murray CJ, Abraham J, Ali MK, et al. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. Jul 10 2013.
  57. National Prevention Council. National Prevention Strategy. June, 2011. Available at: Accessed August 31, 2013.
  58. National Quality Forum. Multiple Chronic Conditions Measurement Framework. May, 2012. Available at: Accessed August 31, 2013.
  59. Noel PH, Frueh BC, Larme AC, et al. Collaborative care needs and preferences of primary care patients with multimorbidity. Health Expect. Mar 2005;8(1):54–63.
  60. Organisation for Economic Co-operation and Development. Meeting the challenge of ageing and multiple morbidities. OECD 50th Anniversary Conference on Health Reform;2011.
  61. Ording AG and Sorensen HT. Concepts of comorbidities, multiple morbidities, complications, and their clinical epidemiologic analogs. Clin Epidemiol. 2013;5:199–203.
  62. Paez KA, Zhao L, Hwang W. Rising out-of-pocket spending for chronic conditions: a ten-year trend. Health Aff (Millwood). Jan-Feb 2009;28(1):15–25.
  63. Parekh AK, Goodman RA, Gordon C, et al. Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep. Jul-Aug 2011;126(4):460–471.
  64. Payne RM. The effect of dioestrus on the racing performance of Greyhounds. Vet J. Jun 18 2013.
  65. Peek CJ, Baird MA, Coleman E. Primary care for patient complexity, not only disease. Fam Syst Health. Dec 2009;27(4):28–-302.
  66. Perruccio AV, Katz JN, Losina E. Health burden in chronic disease: multimorbidity is associated with self-rated health more than medical comorbidity alone. J Clin Epidemiol. Jan 2012;65(1):100–106.
  67. Piette JD, Kerr EA. The impact of comorbid chronic conditions on diabetes care. Diabetes Care. Mar 2006;29(3):725–731.
  68. Piette JD, Valenstein M, Himle J, et al. Clinical complexity and the effectiveness of an intervention for depressed diabetes patients. Chronic Illn. Dec 2011;7(4):267–278.
  69. Quinones AR, Liang J, Bennett JM, et al. How does the trajectory of multimorbidity vary across black, white, and Mexican Americans in middle and old age? J Gerontol B Psychol Sci Soc Sci. Nov 2011;66(6):739–749.
  70. Reuben DB, Tinetti ME. Goal-oriented patient care--an alternative health outcomes paradigm. N Engl J Med. Mar 1 2012;366(9):777–779.
  71. Rich EC, Lipson D, Libersky J, et al. Organizing care for complex patients in the patient-centered medical home. Ann Fam Med. Jan–Feb 2012;10(1):60–62.
  72. Ritchie CS, Zulman DM. Research priorities in geriatric palliative care: multimorbidity. J Palliat Med. Aug 2013;16(8):843–847.
  73. Safford MM, Allison JJ, Kiefe CI. Patient complexity: more than comorbidity. the vector model of complexity. J Gen Intern Med. Dec 2007;22 Suppl 3:382–390.
  74. Salisbury C, Johnson L, Purdy S, et al. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. Jan 2011;61(582):e12–21.
  75. Schneider KM, O'Donnell BE, Dean D. Prevalence of multiple chronic conditions in the United States' Medicare population. Health Qual Life Outcomes. 2009;7:82.
  76. Shippee ND, Shah ND, May CR, et al. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol. Oct 2012;65(10):1041–1051.
  77. Smith SM, Soubhi H, Fortin M, et al. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev. 2012;4:CD006560.
  78. Snyder CF, Frick KD, Herbert RJ, et al. Quality of care for comorbid conditions during the transition to survivorship: differences between cancer survivors and noncancer controls. J Clin Oncol. Mar 20 2013;31(9):1140–1148.
  79. Stange KC. In This Issue: Assessing and Acting on Complexity. Ann Fam Med. 2012;10(2):98–99.
  80. Starfield B and Kinder K. Multimorbidity and its measurement. Health Policy. Nov 2011;103(1):3–8.
  81. Steiner CA and Friedman B. Hospital utilization, costs, and mortality for adults with multiple chronic conditions, Nationwide Inpatient Sample, 2009. Prev Chronic Dis. Apr 2013;10:E62.
  82. Steinman MA, Lee SJ, John Boscardin W, et al. Patterns of multimorbidity in elderly veterans. J Am Geriatr Soc. Oct 2012;60(10):1872–1880.
  83. Tinetti ME, Bogardus ST, Jr., Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. Dec 30 2004;351(27):2870–2874.
  84. Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition--multimorbidity. JAMA. Jun 20 2012;307(23):2493–2494.
  85. Tinetti ME and Studenski SA. Comparative effectiveness research and patients with multiple chronic conditions. N Engl J Med. Jun 30 2011;364(26):2478–2481.
  86. U.S. Department of Health and Human Services. Multiple Chronic Conditions-A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. December, 2010. Available at: Accessed August 31, 2013.
  87. U.S. Department of Health and Human Services. U.S. Department of Health and Human Services Inventory of Programs, Activities, and Initiatives Focused on Improving the Health of Individuals with Multiple Chronic Conditions [HHS Initiative on Multiple Chronic Conditions web site]. Available at: Accessed August 31, 2013.
  88. Valderas JM, Starfield B, Sibbald B, et al. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. Jul-Aug 2009;7(4):357–363.
  89. Versnel N, Welschen LM, Baan CA, et al. The effectiveness of case management for comorbid diabetes type 2 patients; the CasCo study. Design of a randomized controlled trial. BMC Fam Pract. 2011;12:68.
  90. Vogeli C, Shields AE, Lee TA, et al. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med. Dec 2007;22 Suppl 3:391–395.
  91. Wallace RB and Salive ME. The dimensions of multiple chronic conditions: where do we go from here? A commentary on the special collection of Preventing Chronic Disease. Prev Chronic Dis. Apr 2013;10:E59.
  92. Wang V, Liu CF, Bryson CL, et al. Does medication adherence following a copayment increase differ by disease burden? Health Serv Res. Dec 2011;46(6pt1):1963–1985.
  93. Ward BW and Schiller JS. Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010. Prev Chronic Disease. Apr 2013;10:E65.
  94. Weiss KB. Managing complexity in chronic care: an overview of the VA state-of-the-art (SOTA) conference. J Gen Intern Med. Dec 2007;22 Suppl 3:374–378.
  95. Werner RM, Greenfield S, Fung C, et al. Measuring quality of care in patients with multiple clinical conditions: summary of a conference conducted by the Society of General Internal Medicine. J Gen Intern Med. Aug 2007;22(8):1206–1211.
  96. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. Nov 11 2002;162(20):2269–2276.
  97. Working Group on Health Outcomes for Older Persons with Multiple Chronic Conditions. Universal health outcome measures for older persons with multiple chronic conditions. J Am Geriatr Soc. Dec 2012;60(12):2333–2341.
  98. Zhang Y, Thamer M, Kaufman JS, et al. High doses of epoetin do not lower mortality and cardiovascular risk among elderly hemodialysis patients with diabetes. Kidney Int. Sep 2011;80(6):663–669.
  99. Zulman DM, Sussman JB, Chen X, et al. Examining the evidence: a systematic review of the inclusion and analysis of older adults in randomized controlled trials. J Gen Intern Med. Jul 2011;26(7):783–790.
Current as of May 2014
Internet Citation: Selected Publications on Multiple Chronic Conditions, 2002-2013. May 2014. Agency for Healthcare Research and Quality, Rockville, MD.