Chronic Disease Multimorbidity Research Articles

Chronic diseases multi-morbidity among adult patients at Hawassa University Comprehensive Specialized Hospital

BackgroundNon-communicable chronic diseases (NCCDs) multi-morbidity is becoming one of the public health problems in Ethiopia. The objective of this study was to describe the prevalence of NCCDs and multi-morbidity among adult patients at Hawassa University Comprehensive Specialized Hospital (HUCSH).MethodsBetween January and February 2016, a cross-sectional study was carried out among patients aged ⩾ 18 years attending the outpatient department of the hospital. Trained nurses interviewed patients and reviewed medical records. Multi-morbidity was defined as the coexistence of two or more NCCDs in an individual.ResultsTwo hundred twenty seven (55.2%) of the respondents had at least one of the NCCDs and 73 (17.8%) of them had multi-morbidity. The commonest diseases that affected the patients were diseases of the musculoskeletal system. The risk of having NCCDs was highest among patients aged above 44 years (Adjusted odds ratio (AOR) = 2.7, 95% CI 1.5–4.8). Non educated patients (AOR = 1.7, 95% CI 1.0–2.7) and patients with high household income (AOR = 1.6, 95% CI 1.0–2.5) and patients with a body mass index (BMI) of at least 25 (AOR = 2.0, 95% CI 1.1–3.7) had higher odds of having NCCDs. Highest odds of multi-morbidity was observed among patients aged above 44 years (AOR = 4.4, 95% CI 2.2–8.8).ConclusionThe prevalence of NCCDs and multi-morbidity among the study population was high. Identifying and addressing modifiable risk factors; screening, treatment and follow-up of patients with NCCDs could help in reducing the burden of NCCDs multi-morbidity and its effect.

Effect of multimorbidity on gait speed in well‐functioning older people: A population‐based study in Peru

To determine the association between multimorbidity and gait speed in a population-based sample of older people without functional dependency. Data were obtained from a previously made cross-sectional population-based study of individuals aged >60 years carried out in San Martin de Porres, the second most populous district in Lima, Peru. We included well-functioning, independent older people. Exclusion criteria emphasized removing conditions that would impair gait. The exposure of interest was non-communicable chronic disease multimorbidity, and the outcome was gait speed determined by the time required for the participant to walk a distance of 8 m out of a total distance of 10 m. Generalized linear models were used to estimate adjusted gait speed by multimorbidity status. Data from 265 older adults with a median age of 68 years (IQR 63-75 years) and 54% women were analyzed. The median gait speed was 1.06 m/s (SD 0.27) and the mean number of chronic conditions per adult was 1.1 (SD ±1). The difference in mean gait speed between older adults without a chronic condition and those with ≥3 chronic conditions was 0.24 m/s. In crude models, coefficients decreased by a significant exponential factor for every increase in the number of chronic conditions. Further adjustment attenuated these estimates. Slower speed gaits are observed across the spectrum of multimorbidity in older adults without functional dependency. The role of gait speed as a simple indicator to evaluate and monitor general health status in older populations is expanded to include older adults without dependency. Geriatr Gerontol Int 2018; 18: 293-300.

Multimorbidity and Functional Limitations Among Adults 65 or Older, NHANES 2005-2012.

IntroductionThe development of functional limitations among adults aged 65 or older has profound effects on individual and population resources. Improved understanding of the relationship between functional limitations and co-occurring chronic diseases (multimorbidity) is an emerging area of interest. The objective of this study was to investigate the association between multimorbidity and functional limitations among community-dwelling adults 65 or older in the United States and explore factors that modify this association.MethodsWe conducted a cross-sectional analysis of adults aged 65 or older using data from the National Health and Nutrition Examination Survey (NHANES) from 2005 through 2012. We used negative binomial regression to estimate the association between multimorbidity (≥2 concurrent diseases) and functional limitations and to determine whether the association differed by sex or age.ResultsThe prevalence of multimorbidity in this population was 67% (95% confidence interval [CI], 65%–68%). Each additional chronic condition was associated with an increase in the number of functional limitations, and the association was stronger among those aged 75 or older than among those aged 65 to 74. For those aged 65 to 74, each additional chronic condition was associated with 1.35 (95% CI, 1.27–1.43) times the number of functional limitations for men and 1.62 times (95% CI, 1.31–2.02) the number of functional limitations for women. For those 75 or older, the associations increased to 1.71 (95% CI, 1.35–2.16) for men and 2.06 (95% CI, 1.51–2.81) for women for each additional chronic condition.ConclusionMultimorbidity was associated with increases in functional limitations, and the associations were stronger among women than among men and among adults aged 75 or older than among those aged 65 to 74. These findings underscore the importance of addressing age and sex differences when formulating prevention strategies.

Prevalence, survival analysis and multimorbidity of chronic diseases in the general veterinarian-attended horse population of the UK

The average age of the global human population is increasing, leading to increased interest in the effects of chronic disease and multimorbidity on health resources and patient welfare. It has been posited that the average age of the general veterinarian-attended horse population of the UK is also increasing, and therefore it could be assumed that chronic diseases and multimorbidity would pose an increasing risk here also. However, evidence for this trend in ageing is very limited, and the current prevalence of many chronic diseases, and of multimorbidity, is unknown. Using text mining of first-opinion electronic medical records from seven veterinary practices around the UK, Kaplan-Meier and Cox proportional hazard modelling, we were able to estimate the apparent prevalence among veterinarian-attended horses of nine chronic diseases, and to assess their relative effects on median life expectancy following diagnosis. With these methods we found evidence of increasing population age. Multimorbidity affected 1.2% of the study population, and had a significant effect upon survival times, with co-occurrence of two diseases, and three or more diseases, leading to 6.6 and 21.3 times the hazard ratio compared to no chronic disease, respectively. Laminitis was involved in 74% of cases of multimorbidity. The population of horses attended by UK veterinarians appears to be aging, and chronic diseases and their co-occurrence are common features, and as such warrant further investigation.

Enabling personalised medical support for chronic disease management through a hybrid robot-cloud approach

Information and Communication Technology and personal robots could play a fundamental role in efficiently managing chronic diseases and avoiding improper medications. They could support senior citizens with reminders, thus promoting their independent living and quality of life, especially in the presence of several chronic diseases (multimorbidity). In this context, this article proposes a service model for personalised medical support that is able to provide adequate healthcare service by means of a hybrid robot-cloud approach. This service was quantitatively and qualitatively tested to assess the technical feasibility and user acceptability level of the service. The service was tested with 23 older people (65–86 years) in the DomoCasa Lab (Italy). This study demonstrated the feasibility of the proposed hybrid cloud solution and the usability and acceptability were positively evaluated thus confirming the ability to utilise these innovative technologies for active and healthy ageing.

Associations between multimorbidity, healthcare utilisation and health status: evidence from 16 European countries.

with ageing populations and increasing exposure to risk factors for chronic diseases, the prevalence of chronic disease multimorbidity is rising globally. There is little evidence on the determinants of multimorbidity and its impact on healthcare utilisation and health status in Europe. we used cross-sectional data from the Survey of Health, Ageing and Retirement in Europe (SHARE) in 2011-12, which included nationally representative samples of persons aged 50 and older from 16 European nations. Negative binomial and logistic regression models were used to assess the association between number of chronic diseases and healthcare utilisation, self-perceived health, depression and reduction of functional capacity. overall, 37.3% of participants reported multimorbidity; the lowest prevalence was in Switzerland (24.7%), the highest in Hungary (51.0%). The likelihood of having multimorbidity increased substantially with age. Number of chronic conditions was associated with greater healthcare utilisation in both primary (regression coefficient for medical doctor visits = 0.29, 95% CI = 0.27-0.30) and secondary setting (adjusted odds ratio (AOR) for having any hospitalisation in the last year = 1.49, 95% CI = 1.42-1.55) in all countries analysed. Number of chronic diseases was associated with fair/poor health status (AOR 2.13, 95% CI = 2.03-2.24), being depressed (AOR 1.48, 95% CI = 1.42-1.54) and reduced functional capacity (AOR 2.12, 95% CI = 2.02-2.22). multimorbidity is associated with greater healthcare utilisation, worse self-reported health status, depression and reduced functional capacity in European countries. European health systems should prioritise improving the management of patients with multimorbidity to improve their health status and increase healthcare efficiency.

Health-related quality of life mediates associations between multi-morbidity and depressive symptoms in Chinese primary care patients.

Background.Qualifying the relationship between multi-morbidity, health-related quality of life (HRQOL) and depressive symptoms in primary care can help to inform the development of appropriate interventions and services which can help to enhance HRQOL in patients with chronic disease.Objective.The objective of this study was to determine whether the physical aspect of HRQOL mediates the relationship between chronic disease multi-morbidity and depressive symptoms in Chinese primary care patients.Methods.A cross-sectional survey was conducted on patients recruited from the waiting rooms of 59 primary care clinics distributed across Hong Kong. About 9259 subjects were included for the mediation model analysis. The primary outcome was level of depressive symptoms as measured by the Patient Health Questionniare 9. The mediation model was tested using a bootstrapping method.Results.The prevalence of chronic disease was 50.4%, with 25.4% having two or more co-morbidities. The relationship between multi-morbidity and depressive symptoms was found to be mediated by the Physical Component Summary score of the SF-12 v2. Further analysis found the general health (GH) and role physical domains of the SF-12 were the strongest mediators, followed by bodily pain and physical functioning (PF).Conclusion.To enhance the functional capacity of primary care patients with co-existing chronic disease and depressive symptoms, health care interventions should be directed at improving the physical aspects of HRQOL, in particular enhancing patients’ GH perception, role functioning and PF, and to better manage chronic pain.

Prevalence and Patterns of Chronic Disease Pairs and Multimorbidity among Older Chinese Adults Living in a Rural Area

BackgroundThe burden of chronic diseases in China is substantial now. Data on patterns of chronic diseases and multimorbidity among older adults, especially among those living in rural areas, are sparse.ObjectiveWe aim to investigate the prevalence and patterns of chronic disease pairs and multimorbidity in elderly people living in rural China.MethodsThis population-based study included 1480 adults aged 60 years and over (mean age 68.5 years, 59.4% women) living in a rural community. Data were derived from the Confucius Hometown Aging Project in Shandong, China (June 2010-July 2011). Chronic diseases were diagnosed through face-to-face interviews, clinical examinations, and laboratory tests. Patterns of chronic disease pairs and multimorbidity were explored using logistic regression and exploratory factor analyses.ResultsThe prevalence of individual chronic diseases ranged from 3.0% for tumor to 76.4% for hypertension, and each disease was often accompanied with three or more other chronic diseases. The observed prevalence of pairs of chronic conditions exceeded the expected prevalence for several conditions, such as cardiovascular diseases and metabolic disorders, as well as pulmonary diseases and degenerative disorders. Chronic multimorbidity (≥2 chronic diseases) affected more than 90% of subjects, and two patterns of chronic multimorbidity were identified: cardiopulmonary-mental-degenerative disorder pattern (overall prevalence, 58.2%), and cerebrovascular-metabolic disorder pattern (62.6%). Prevalence of the cardiopulmonary-mental-degenerative disorder pattern increased with age, and was higher in men than women; whereas prevalence of the cerebrovascular-metabolic disorder pattern was higher in women than in men but did not vary by age.ConclusionChronic multimorbidity was highly prevalent among older Chinese adults living in rural areas, and there were specific patterns of the co-occurrence of chronic diseases. Effort is needed to identify possible preventative strategies based on the potential clustering of chronic diseases.

Prevalence and patterns of chronic disease multimorbidity and associated determinants in Canada.

Multimorbidity is increasingly recognized as a key issue in the prevention and management of chronic diseases. We examined the prevalence and correlates of chronic disease multimorbidity in the general adult Canadian population in relation to age and other key determinants. We extracted data from the Canadian Community Health Survey 2011/12 on 105 416 Canadian adults. We analysed the data according to the number of multimorbidities (defined as 2+ or 3+ diseases from a list of 9) and examined the determinants of multimorbidity using regression analyses. Our findings show that 12.9% of Canadians report 2+ chronic diseases and 3.9% report 3+ chronic diseases. Those reporting 3 or more chronic diseases were more likely to be female, older, living in the lowest income quintile and to have not completed high school. In the overall population, social deprivation is associated with a 3.7 odds of multimorbidity, but when examined across age groups, the odds of multimorbidity were notably higher in middle age, 7.5 for those aged 35 to 49 years and 5.4 for those aged 50 to 64 years. As the proportion of Canadians living with multiple chronic diseases increases, we need to assess chronic disease from a holistic perspective that captures multimorbidity and upstream factors, to facilitate broader and more context-appropriate associations with healthy living, quality of life, health care costs and mortality. Special consideration should be given to the role that social deprivation plays in the development of multimorbidity. Canadians living in the lowest socioeconomic group are not only more likely to develop multimorbidity, but the onset of multimorbidity is also likely to be significantly earlier.

Multimorbidity of chronic diseases and health care utilization in general practice

BackgroundMultimorbidity is common among ageing populations and it affects the demand for health services. The objective of this study was to examine the relationship between multimorbidity (i.e. the number of diseases and specific combinations of diseases) and the use of general practice services in the Dutch population of 55 years and older.MethodsData on diagnosed chronic diseases, contacts (including face-to-face consultations, phone contacts, and home visits), drug prescription rates, and referral rates to specialised care were derived from the Netherlands Information Network of General Practice (LINH), limited to patients whose data were available from 2006 to 2008 (N = 32,583). Multimorbidity was defined as having two or more out of 28 chronic diseases. Multilevel analyses adjusted for age, gender, and clustering of patients in general practices were used to assess the association between multimorbidity and service utilization in 2008.ResultsPatients diagnosed with multiple chronic diseases had on average 18.3 contacts (95% CI 16.8 19.9) per year. This was significantly higher than patients with one chronic disease (11.7 contacts (10.8 12.6)) or without any (6.1 contacts (5.6 6.6)). A higher number of chronic diseases was associated with more contacts, more prescriptions, and more referrals to specialized care. However, the number of contacts per disease decreased with an increasing number of diseases; patients with a single disease had between 9 to 17 contacts a year and patients with five or more diseases had 5 or 6 contacts per disease per year. Contact rates for specific combinations of diseases were lower than what would be expected on the basis of contact rates of the separate diseases.ConclusionMultimorbidity is associated with increased health care utilization in general practice, yet the increase declines per additional disease. Still, with the expected rise in multimorbidity in the coming decades more extensive health resources are required.

Multimorbidity and Comorbidity of Chronic Diseases among the Senior Australians: Prevalence and Patterns

Understanding patterns and identifying common clusters of chronic diseases may help policymakers, researchers, and clinicians to understand the needs of the care process better and potentially save both provider and patient time and cost. However, only limited research has been conducted in this area, and ambiguity remains as those limited previous studies used different approaches to identify common clusters and findings may vary with approaches. This study estimates the prevalence of common chronic diseases and examines co-occurrence of diseases using four approaches: (i) identification of the most occurring pairs and triplets of comorbid diseases; performing (ii) cluster analysis of diseases, (iii) principal component analysis, and (iv) latent class analysis. Data were collected using a questionnaire mailed to a cross-sectional sample of senior Australians, with 4574 responses. Eighty-two percent of respondents reported having at least one chronic disease and over 52% reported having at least two chronic diseases. Respondents suffering from any chronic diseases had an average of 2.4 comorbid diseases. Three defined groups of chronic diseases were identified: (i) asthma, bronchitis, arthritis, osteoporosis and depression; (ii) high blood pressure and diabetes; and (iii) cancer, with heart disease and stroke either making a separate group or “attaching” themselves to different groups in different analyses. The groups were largely consistent across the approaches. Stability and sensitivity analyses also supported the consistency of the groups. The consistency of the findings suggests there is co-occurrence of diseases beyond chance, and patterns of co-occurrence are important for clinicians, patients, policymakers and researchers. Further studies are needed to provide a strong evidence base to identify comorbid groups which would benefit from appropriate guidelines for the care and management of patients with particular disease clusters.

Can chronic multimorbidity explain the age-related differences in strength, speed and balance in older adults?

It is known that physical performance declines with age in general, however there remains much to be understood in terms of age-related differences amongst older adults across a variety of physical components (such as speed, strength and balance), and particularly in terms of the role played by multimorbidity of chronic diseases. We aimed to detect the age-related differences across four components of physical performance and to explore to what extent chronic diseases and multimorbidity may explain such differences. We analyzed cross-sectional data from a population-based sample of 3323 people, aged 60 years and older from the SNAC-K study, Stockholm, Sweden. Physical performance was assessed by trained nurses using several tests (grip strength, walking speed, balance and chair stands). Clinical diagnoses were made by the examining physician based on clinical history and examination. Censored normal regression analyses showed that the 72-90+ year-old persons had 17-40% worse grip strength, 44-86% worse balance, 30-86% worse chair stand score, and 21-59% worse walking speed, compared with the 60-66 year-old persons. Chronic diseases were strongly associated with physical impairment, and this association was particularly strong among the younger men. However, chronic diseases explained only some of the age-related differences in physical performance. When controlling for chronic diseases in the analyses, the age-related differences in physical performance changed 1-11%. In spite of the strong association between multimorbidity and physical impairment, chronic morbidities explained only a small part of the age-related differences in physical performance.

Chronic disease multimorbidity transitions across healthcare interfaces and associated costs: a clinical-linkage database study

ObjectiveTo investigate multimorbidity transitions from general practice populations across healthcare interfaces and the associated healthcare costs.DesignClinical-linkage database study.SettingPopulation (N=60 660) aged 40 years and over registered with 53 general practices...

Inappropriate Use of Psychotropic Drugs in Older Individuals: Implications for Practice

Frailty at old age and institutionalization in nursing homes are often associated with multiple chronic diseases (multimorbidity) requiring multiple medications (polypharmacy). Among these chronic conditions, mental health problems (e.g., dementia, depression and insomnia) are common. Psychotropic drugs are frequently used as a treatment approach for these conditions, and the prevalence of their use is high among community-dwelling older adults, but even higher in nursing homes. Furthermore, within the problem of polypharmacy and inappropriate prescribing, psychotropic drugs (defined in this article as antipsychotics, benzodiazepines and antidepressants) constitute a significant proportion. The use of psychotropics in older adults remains controversial given the risk of adverse effects, in contrast to the limited effectiveness. Guidelines advise a thorough risk–benefit analysis before the initiation of psychotropics, in addition to time-limited use and discontinuation. In the future, serious efforts should be undertaken to tackle the burden of inappropriate psychotropic prescribing in older adults by incorporating a multidisciplinary approach and by offering credible alternatives.

Multimorbidity of chronic diseases among adult patients presenting to an inner-city clinic in Ghana

BackgroundVery little is known about multimorbidity and chronic diseases in low and middle income countries, particularly Sub-Saharan Africa, and more information is needed to guide the process of adapting the health systems in these countries to respond adequately to the increasing burden of chronic diseases. We conducted a hospital-based survey in an urban setting in Ghana to determine the prevalence of multimorbidity and its associated risk factors among adult patients presenting to an inner city clinic.MethodsBetween May and June 2012, we interviewed adult patients (aged 18 years and above) attending a routine outpatient clinic at an inner-city hospital in Accra using a structured questionnaire. We supplemented the information obtained from the interviews with information obtained from respondents’ health records. We used logistic regression analyses to explore the risk factors for multimorbidity.ResultsWe interviewed 1,527 patients and retrieved matching medical records for 1,399 (91.6%). The median age of participants was 52.1 years (37–64 years). While the prevalence of multimorbidity was 38.8%, around half (48.6%) of the patients with multimorbidity were aged between 18–59 years old. The most common combination of conditions was hypertension and diabetes mellitus (36.6%), hypertension and musculoskeletal conditions (19.9%), and hypertension and other cardiovascular conditions (11.4%). Compared with patients aged 18–39 years, those aged 40–49 years (OR 4.68, 95% CI: 2.98–7.34), 50–59 years (OR 12.48, 95% CI: 8.23–18.92) and 60 years or older (OR 15.80, 95% CI: 10.66–23.42) were increasingly likely to present with multimorbidity. While men were less likely to present with multimorbidity, (OR 0.71, 95% CI: 0.45–0.94, p = 0.015), having a family history of any chronic disease was predictive of multimorbidity (OR 1.43, 95% CI: 1.03–1.68, p = 0.027).ConclusionsMultimorbidity is a significant problem in this population. By identifying the risk factors for multimorbidity, the results of the present study provide further evidence for informing future policies aimed at improving clinical case management, health education and medical training in Ghana.

Multimorbidity and comorbidity in the Dutch population – data from general practices

BackgroundMultimorbidity is increasingly recognized as a major public health challenge of modern societies. However, knowledge about the size of the population suffering from multimorbidity and the type of multimorbidity is scarce. The objective of this study was to present an overview of the prevalence of multimorbidity and comorbidity of chronic diseases in the Dutch population and to explore disease clustering and common comorbidities.MethodsWe used 7 years data (2002–2008) of a large Dutch representative network of general practices (212,902 patients). Multimorbidity was defined as having two or more out of 29 chronic diseases. The prevalence of multimorbidity was calculated for the total population and by sex and age group. For 10 prevalent diseases among patients of 55 years and older (N = 52,014) logistic regressions analyses were used to study disease clustering and descriptive analyses to explore common comorbid diseases.ResultsMultimorbidity of chronic diseases was found among 13% of the Dutch population and in 37% of those older than 55 years. Among patients over 55 years with a specific chronic disease more than two-thirds also had one or more other chronic diseases. Most disease pairs occurred more frequently than would be expected if diseases had been independent. Comorbidity was not limited to specific combinations of diseases; about 70% of those with a disease had one or more extra chronic diseases recorded which were not included in the top five of most common diseases.ConclusionMultimorbidity is common at all ages though increasing with age, with over two-thirds of those with chronic diseases and aged 55 years and older being recorded with multimorbidity. Comorbidity encompassed many different combinations of chronic diseases. Given the ageing population, multimorbidity and its consequences should be taken into account in the organization of care in order to avoid fragmented care, in medical research and healthcare policy.

Multimorbidity Patterns in Primary Care: Interactions among Chronic Diseases Using Factor Analysis

ObjectivesThe primary objective of this study was to identify the existence of chronic disease multimorbidity patterns in the primary care population, describing their clinical components and analysing how these patterns change and evolve over time both in women and men. The secondary objective of this study was to generate evidence regarding the pathophysiological processes underlying multimorbidity and to understand the interactions and synergies among the various diseases.MethodsThis observational, retrospective, multicentre study utilised information from the electronic medical records of 19 primary care centres from 2008. To identify multimorbidity patterns, an exploratory factor analysis was carried out based on the tetra-choric correlations between the diagnostic information of 275,682 patients who were over 14 years of age. The analysis was stratified by age group and sex.ResultsMultimorbidity was found in all age groups, and its prevalence ranged from 13% in the 15 to 44 year age group to 67% in those 65 years of age or older. Goodness-of-fit indicators revealed sample values between 0.50 and 0.71. We identified five patterns of multimorbidity: cardio-metabolic, psychiatric-substance abuse, mechanical-obesity-thyroidal, psychogeriatric and depressive. Some of these patterns were found to evolve with age, and there were differences between men and women.ConclusionsNon-random associations between chronic diseases result in clinically consistent multimorbidity patterns affecting a significant proportion of the population. Underlying pathophysiological phenomena were observed upon which action can be taken both from a clinical, individual-level perspective and from a public health or population-level perspective.

Prevalence of disability according to multimorbidity and disease clustering: a population-based study.

The prevalence of chronic diseases has increased with population ageing, and research has attempted to elucidate the correlation between chronic diseases and disability. However, most studies in older populations have focused on the effect of single disabling conditions, even though most older adults have more than one chronic disease (multimorbidity). The aims of this study were to evaluate the association of disability with disease, in terms of multimorbidity and specified pairs of diseases, in a population-based study of older adults. Materials and Methods: Using the Kungsholmen Project, we estimated the prevalence of disability by the number of chronic diseases, disease status by organ systems, and in specific pairs of chronic conditions, in a Swedish population (n=1,099; ≥77 years). Disability was defined as need of assistance in at least one activity of daily living (Katz index). Functional disability was seen in 17.9% of participants. It increased as the number of chronic diseases increased. The prevalence of disability varied greatly amongst specific pairs of diseases: from 6.7% in persons affected by hypertension and atrial fibrillation to 82.4% in persons affected by dementia and hip fracture. In multivariate logistic regression models, the disease pairs that were significantly associated with the highest increased relative odds of disability contained dementia (dementia-hip fracture, dementia-CVD, and dementia-depression). Our findings suggest specific pairs of diseases are much more highly associated with disability than others, particularly diseases coupled with dementia. This knowledge may improve prevention of disablement and planning of resource distribution. Journal of Comorbidity 2011;1:11-18.

Improving quality of chronic care by integrating the primary care setting

Purpose: One of the main barriers for further improving the quality of chronic care was the absence of performance-based financing. With the introduction of a Diagnosis-Based Costing method (DBC) within primary care, a new organisational model is implemented in the region Maastricht. This integrated care model includes all relevant stakeholders, such as GPs, district nurses, dieticians, nurse practitioners, practice assistants, physiotherapists and hospital-based specialists. Aim is to optimise the quality of fragmented primary care for chronically ill within the existing budget restraints or, if even possible, to diminish the present costs for chronic care. Context and data sources: Increasing prevalence of chronic illnesses, an ageing society and the observation that existing care systems approach mostly insufficiently to specific health problems and patients’ needs asked for redesigning the existing healthcare system. We started by focussing on primary diabetes and COPD care. For the delivery of diabetes and COPD care within the entire primary care setting health care insurance companies contract with GPs only. GPs act as gatekeepers and coordinate the delivery of care within the primary care setting. Evidence-based medical guidelines and evidence about the organisation of respectively integrated diabetes and COPD care were used to outline care in multidisciplinary protocols. Referral criteria for secondary care are formulated as well. Within this protocol hospital-based specialists deliver specialized care while working in the GPs electronic patient file. Case description: In 2007 and 2008, respectively 6390 and 6700 diabetes patients, derived form 87 GPs, have been included in the DBCcohorts. The DBC COPD has been implemented in October last year, until now 2253 patients are registered. DBCs for cardiovascular diseases and for depression and anxiety are under construction and will be implemented by the end of this year. All healthcare givers register their delivered care into the same electronic patient file. Preliminary conclusions/discussion: Based on the preliminary data it can be concluded that the integrated care model has been adopted by professionals in the primary care setting, patients and the health care insurance companies. Moreover, agreement has been reached in the process of care delivery, the indicators for performance-based costing and the collection of data for care and research purposes. Matches and gaps between the actual delivered care and the protocol are explained by the Chronic Care Model and the Management Control Theory (an article is accepted for international publication). Patient outcomes, cost-effectiveness and benefits of these programmes are now subject of investigation. The main challenge for the future is to answer the question whether such disease-specific driven approaches remain suitable for patients suffering from more than one chronic disease (multi-morbidity).