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The American Journal of Managed Care February 2011
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Effect of Multiple Chronic Conditions Among Working-Age Adults
James M. Naessens, ScD; Robert J. Stroebel, MD; Dawn M. Finnie, MPA; Nilay D. Shah, PhD; Amy E. Wagie, BA; William J. Litchy, MD; Patrick J. F. Killinger, MA; Thomas J. D. O'Byrne, BS; Douglas L. Wood, MD; and Robert E. Nesse, MD
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Kostas Athanasakis, MSc; Anastasis G. Skroumpelos, MSc; Vassiliki Tsiantou, MSc; Katerina Milona, MSc; and John Kyriopoulos, PhD
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Richard J. Butler, PhD; Taylor K. Davis, BA; William G. Johnson, PhD; and Harold H. Gardner, MD
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Gary Y. Leung, PhD; Jianying Zhang, MD, MPH; Wen-Chieh Lin, PhD; and Robin E. Clark, PhD
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Karen J. Wernli, PhD; Erin J. Aiello Bowles, MPH; Sebastien Haneuse, PhD; Joanne G. Elmore, MD, MPH; and Diana S.M. Buist, PhD, MPH
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Effect of Multiple Chronic Conditions Among Working-Age Adults

James M. Naessens, ScD; Robert J. Stroebel, MD; Dawn M. Finnie, MPA; Nilay D. Shah, PhD; Amy E. Wagie, BA; William J. Litchy, MD; Patrick J. F. Killinger, MA; Thomas J. D. O'Byrne, BS; Douglas L. Wood, MD; and Robert E. Nesse, MD
Multiple chronic conditions among working-age adults lead to high costs over many years. Understanding how to effectively manage such patients is an important challenge.
Although we used a standard classification of chronic conditions, another study limitation was that our identification source of chronic conditions was based on claims data rather than on medical records. This may have undercounted the prevalence of chronic conditions.

Implications for Practice, Policy, and Patients

The best care management approach for the workingage adult population may be a stratified approach. For most healthy (or presymptomatic) individuals, the primary focus is to keep them healthy. For individuals with 1 or 2 chronic conditions, the main focus is to maintain function and to prevent chronic conditions from progressing. Increasing the availability of nonvisit care and incorporating aspects of a medical home should foster this goal.25-27 For the small group of individuals with multiple chronic conditions, more active and individualized management is necessary.

Focusing on chronic conditions commonly addressed by disease management programs, Charlson et al28 found small cost differences among patients with only 1 chronic  condition, but costs increased rapidly as the number of comorbidities increased. They concluded that a patient-centered approach rather than a condition-centered approach is  needed to address the highest-cost patients with multiple comorbidities. With increasing prevalence of this type of patient, refocusing guidelines to meet patient-specific needs in managing multiple diseases may be required.15,29

Future Research

A traditional primary care model does not readily support a stratified approach to care delivery. Usual care delivery through in-office physician visits provides limited flexibility to address varying levels of need. A multidisciplinary team–based approach extending beyond the confines of the office could support the stratification of care to meet the varying needs of a population. For healthy patients, much care and management could be delivered in nonoffice settings by nonphysicians or via computer or phone.30-32 Patients with 1 or 2 chronic conditions can receive evidence-based planned care delivered by nurses, pharmacists, nurse practitioners or physician assistants, and physicians.6,33-38

For patients with multiple chronic conditions, a more useful strategy will focus on a patient’s unique care coordination needs rather than on specific chronic conditions. In a primary care setting, patients with multiple chronic conditions pose a challenge.5,29,39,40 Again, guidelines for management of multiple diseases may need to be changed to meet specific needs of the increasingly prevalent complex patient with multiple chronic conditions.15,29


While it is well documented that multiple chronic conditions are common in the population 65 years and older, our research shows that comorbid illness is also prevalent among the working-age population aged 18 to 64 years and drives high costs that persist over time. Effective healthcare delivery requires an understanding of how to best manage patients with multiple chronic conditions. It is imperative that we integrate the necessary building blocks to manage the complex patient in an effective system of care, identify additional elements needed to improve patient quality of life, and reduce costs and utilization of inpatient care and emergency services.

Author Affiliations: From the Division of Health Care Policy & Research (JMN, DMF, NDS, AEW, PJFK, TJDO, DLW), Department of Internal Medicine (RJS), (Department of Neurology (WJL), Health System Administration (REN), Mayo Clinic, Rochester, MN.


Funding Source: This study was funded by the Mayo Clinic.


Author Disclosures: The authors (JMN, RJS, DMF, NDS, AEW, WJL, PJFK, TJDO, DLW, REN) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.


Authorship Information: Concept and design (JMN, RJS, NDS, WJL, DLW, REN); acquisition of data (JMN, AEW, DLW); analysis and interpretation of data (JMN, RJS, DMF, NDS, AEW, WJL, TJDO, DLW, REN); drafting of the manuscript (JMN, RJS, DMF, AEW, WJL, PJFK, TJDO, DLW, REN); critical revision of the manuscript for important intellectual content (JMN, RJS, DMF, NDS, WJL, PJFK, TJDO, DLW, REN); statistical analysis (JMN, NDS, AEW); obtaining funding (JMN, PJFK, DLW); administrative, technical, or logistic support (JMN, RJS, DMF, NDS, PJFK, DLW); and supervision (JMN, PJFK, REN).


Address correspondence to: Dawn M. Finnie, MPA, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail:

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