Abstract
BackgroundEvidence is limited on racial/ethnic group disparities in multimorbidity and associated health outcomes in low- and middle-income countries hampering effective policies and clinical interventions to address health inequalities.MethodsThis study assessed race/ethnic and socioeconomic disparities in the prevalence of multimorbidity and associated healthcare utilisation, costs and death in Rio de Janeiro, Brazil. A cross-sectional analysis was carried out of 3,027,335 individuals registered with primary healthcare (PHC) services. Records included linked data to hospitalisation, mortality, and welfare-claimant (Bolsa Família) records between 1 Jan 2012 and 31 Dec 2016. Logistic and Poisson regression models were carried out to assess the likelihood of multimorbidity (two or more diagnoses out of 53 chronic conditions), PHC use, hospital admissions and mortality from any cause. Interactions were used to assess disparities.ResultsIn total 13,509,633 healthcare visits were analysed identifying 389,829 multimorbid individuals (13%). In adjusted regression models, multimorbidity was associated with lower education (Adjusted Odds Ratio (AOR): 1.26; 95%CI: 1.23,1.29; compared to higher education), Bolsa Família receipt (AOR: 1.14; 95%CI: 1.13,1.15; compared to non-recipients); and black race/ethnicity (AOR: 1.05; 95%CI: 1.03,1.06; compared to white). Multimorbidity was associated with more hospitalisations (Adjusted Rate Ratio (ARR): 2.75; 95%CI: 2.69,2.81), more PHC visits (ARR: 3.46; 95%CI: 3.44,3.47), and higher likelihood of death (AOR: 1.33; 95%CI: 1.29,1.36). These associations were greater for multimorbid individuals with lower educational attainment (five year probability of death 1.67% (95%CI: 1.61,1.74%) compared to 1.13% (95%CI: 1.02,1.23%) for higher education), individuals of black race/ethnicity (1.48% (95%CI: 1.41,1.55%) compared to 1.35% (95%CI: 1.31,1.40%) for white) and individuals in receipt of welfare (1.89% (95%CI: 1.77,2.00%) compared to 1.35% (95%CI: 1.31,1.38%) for non-recipients).ConclusionsThe prevalence of multimorbidity and associated hospital admissions and mortality are greater in individuals with black race/ethnicity and other deprived socioeconomic groups in Rio de Janeiro. Interventions to better prevent and manage multimorbidity and underlying disparities in low- and middle-income country settings are needed.
Highlights
Evidence is limited on racial/ethnic group disparities in multimorbidity and associated health outcomes in low- and middle-income countries hampering effective policies and clinical interventions to address health inequalities
77% of noncommunicable disease (NCD) deaths and 82% of NCD DALYs lost globally are in low- and middle-income countries (LMICs) [1]
Individuals with deprived socioeconomic status and low educational attainment have a higher prevalence of multimorbidity [7,8,9,10,11,12,13], including in LMICs [14,15,16]
Summary
Appropriate prevention and management of risk factors and chronic conditions is essential to address the NCD burden [3]. Multimorbidity (two or more chronic conditions) strains health systems attempting to manage the growing burden of NCDs. Multimorbid individuals report worse quality of life [4] and increased functional decline [5], incur higher healthcare costs [5], and are at increased risk of death [6]. Individuals with deprived socioeconomic status and low educational attainment have a higher prevalence of multimorbidity [7,8,9,10,11,12,13], including in LMICs [14,15,16]. Accumulation of risk factors, chronic stress, and poorer healthcare access in deprived socioeconomic groups drive these disparities. Multimorbidity onset can be up to 15 years earlier in deprived populations compared to affluent populations [17]
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