ABSTRACT

Objective

To describe the prevalence of health service use due to multimorbidity according to sociodemographic and health characteristics of the Brazilian population; to analyze the relationship between multimorbidity and the use of health services.

Methods

This was a cross-sectional study using data from the 2019 National Health Survey. The outcomes were seeking health services in the last 15 days, medical consultation and hospitalization in the previous 12 months. Multimorbidity was defined as ≥ 2 chronic diseases. Associations were assessed using Poisson regression.

Results

Of the 81,768 individuals, prevalence of seeking health services among individuals with multimorbidity was 38.0% higher (95%CI 1.31;1.45), medical appointments, 11.0% higher (95%CI 1.10;1.12), and 56.0% higher for hospitalizations (95%CI 1.44;1.70), compared to those without multimorbidity. This relationship was higher for seeking health services and medical appointments among male.

Conclusion

The use of health services was higher among those with multimorbidity, but different between the types of health services used and sexes.

Keywords
Health Services; Multimorbidity; Cross-Sectional Studies; Epidemiological Surveys; Chronic disease

Study contributions

Main results

Having multimorbidity increased the use of health services, even after progressive adjustment by sociodemographic characteristics and health needs. This relationship was greater among males for medical consultations.

Implications for services

Greater use of health services by individuals with multiple non-communicable diseases (NCDs) points to the need for changes in care models, with focus on continuity of care.

Perspectives

Health services should focus on continuous, coordinated and comprehensive approaches to the care of people with multimorbidity, thus seeking to increase the efficiency and quality of care provided to this population.

Keywords
Health Services; Multimorbidity; Cross-Sectional Studies; Epidemiological Surveys; Chronic disease

RESUMEN

Objetivo

Describir prevalencia de uso de servicios de salud por multimorbilidad según características sociodemográficas de salud de población brasileña; analizar relación entre multimorbilidad y utilización de servicios de salud.

Métodos

Estudio transversal con datos de Encuesta Nacional de Salud de 2019.

Resultados

fueron búsqueda de servicios de salud en últimos quince días; consulta médica y hospitalizaciones en últimos doces meses. Multimorbilidad se definió como ≥ 2 enfermedades crónicas. Asociaciones se evaluaron mediante regresión de Poisson.

Resultados

De los 81.768 individuos, prevalencia de búsqueda de servicios de salud entre los individuos con multimorbilidad fue 38,0% mayor (IC₉₅% 1,31;1,45), citas médicas 11,0% mayor (IC₉₅% 1,10;1,12) y 56,0% mayor para hospitalizaciones (IC₉₅% 1,44;1,70), en comparación con aquellos sin multimorbilidad. Esta relación fue mayor para búsqueda y citas médicas entre el sexo masculino.

Conclusión

El uso de los servicios de salud fue mayor entre aquellos con multimorbilidad, pero diferente entre los tipos de servicios de salud utilizados y sexos.

Palabras llave
Servicios de Salud; Multimorbilidad; Estudios Transversales; Encuestas Epidemiológicas; Enfermedad crónica

INTRODUCTION

Multimorbidity is often defined as the co-occurrence of multiple chronic medical conditions in the same person.¹1 Johnston MC, Crilly M, Black C, Prescott GJ, Mercer SW. Defining and measuring multimorbidity: a systematic review of systematic reviews. Eur J Public Health. 2019;29(1):182-9. doi: 10.1093/eurpub/cky098.
https://doi.org/10.1093/eurpub/cky098...

2 Diederichs C, Berger K, Bartels DB. The measurement of multiple chronic diseases–a systematic review on existing multimorbidity indices. J Gerontol A Biol Sci Med Sci. 2011;66(3):301-11. doi: 10.1093/gerona/glq208.
https://doi.org/10.1093/gerona/glq208... -³3 Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury C. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med. 2012;10(2):134-41. doi: 10.1370/afm.1363.
https://doi.org/10.1370/afm.1363... The progressive increase in individuals with multimorbidity is recognized as one of the main challenges for health professionals and public health systems.⁴4 Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011;10(4):430-9. doi: 10.1016/j.arr.2011.03.003.
https://doi.org/10.1016/j.arr.2011.03.00... ,⁵5 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43. doi: 10.1016/S0140-6736(12)60240-2.
https://doi.org/10.1016/S0140-6736(12)60...

In Brazil, prevalence of multimorbidity was estimated at 24.2% in 2013, being more common in women, among those with less education and older individuals.⁶6 Rzewuska M, Azevedo-Marques JM, Coxon D, Zanetti ML, Zanetti AC, Franco LJ, et al. Epidemiology of multimorbidity within the Brazilian adult general population: evidence from the 2013 National Health Survey (PNS 2013). PLoS One. 2017;12(2):e0171813. doi: 10.1371/journal.pone.0171813.
https://doi.org/10.1371/journal.pone.017... Furthermore, it was found that in Brazil people develop multimorbidity at a younger age than people in wealthier countries, and women, ten years earlier than men.⁶6 Rzewuska M, Azevedo-Marques JM, Coxon D, Zanetti ML, Zanetti AC, Franco LJ, et al. Epidemiology of multimorbidity within the Brazilian adult general population: evidence from the 2013 National Health Survey (PNS 2013). PLoS One. 2017;12(2):e0171813. doi: 10.1371/journal.pone.0171813.
https://doi.org/10.1371/journal.pone.017...

Souza & Braga (2020) found that in Brazil in 2013, prevalence of people with multimorbidity seeking health services was two times greater in relation to those without multimorbidity.⁷7 Souza ASS, Braga JU. Trends in the use of health services and their relationship with multimorbidity in Brazil, 1998-2013. BMC Health Serv Res. 2020;20(1):1080. doi: 10.1186/s12913-020-05938-4.
https://doi.org/10.1186/s12913-020-05938... That study also found that presence of multimorbidity increased the prevalence of medical consultations by 16% among men and 11% among women; and hospitalizations by 55% among men and 45% among women in 2013.⁷7 Souza ASS, Braga JU. Trends in the use of health services and their relationship with multimorbidity in Brazil, 1998-2013. BMC Health Serv Res. 2020;20(1):1080. doi: 10.1186/s12913-020-05938-4.
https://doi.org/10.1186/s12913-020-05938... In view of high demand for health services, case management programs for individuals with multimorbidity are being developed and evaluated around the world, but there are still no Brazilian guidelines on what constitutes the best care for these people.⁸8 Bruin SR, Versnel N, Lemmens LC, Molema CCM, Schellevis FG, Nijpels G, et al. Comprehensive care programs for patients with multiple chronic conditions: a systematic literature review. Health Policy. 2012;107(2-3):108-45. doi: 10.1016/j.healthpol.2012.06.006.
https://doi.org/10.1016/j.healthpol.2012...

Therefore, knowing the main determinants of multimorbidity and its association with different health services contributes to the development of effective health protocols and policies, which aim at continuous, coordinated and comprehensive, person-centered approaches.⁹9 Harkness E, Macdonald W, Valderas J, Coventry P, Gask L, Bower P. Identifying psychosocial interventions that improve both physical and mental health in patients with diabetes: a systematic review and meta-analysis. Diabetes Care. 2010;33(4):926-30. doi: 10.2337/dc09-1519.
https://doi.org/10.2337/dc09-1519... Despite high prevalence of multimorbidity in Brazil, few published studies have examined its relationship with health services for the entire Brazilian population.⁷7 Souza ASS, Braga JU. Trends in the use of health services and their relationship with multimorbidity in Brazil, 1998-2013. BMC Health Serv Res. 2020;20(1):1080. doi: 10.1186/s12913-020-05938-4.
https://doi.org/10.1186/s12913-020-05938... ,¹⁰10 Souza ASS, Faerstein E, Werneck GL. Multimorbidity and use of health services by individuals with restrictions on habitual activities: the Pro-Saude Study. Cad Saude Publica. 2019;35(11):e00155118. doi: 10.1590/0102-311X00155118.
https://doi.org/10.1590/0102-311X0015511... ,¹¹11 Shi X, Lima SMS, Mota CMM, Lu Y, Stafford RS, Pereira CV. Prevalence of multimorbidity of chronic noncommunicable diseases in Brazil: population-based study. JMIR Public Health Surveill. 2021;7(11):e29693. doi: 10.2196/29693.
https://doi.org/10.2196/29693...

As such, this study sought to describe the prevalence of the use of different health services due to multimorbidity according to sociodemographic and health characteristics of the Brazilian population, as well as to analyze association between them.

METHODS

This was a cross-sectional study using data from the National Health Survey (Pesquisa Nacional de Saúde - PNS) conducted in 2019. The PNS survey was carried out by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE) in partnership with the Ministry of Health. The survey sampling was carried out in three selection stages and is representative of the Brazilian population. Details of the sampling process can be accessed in a specific publication.¹²12 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude. 2020;29(5):e2020315. doi: 10.1590/S1679-49742020000500004.
https://doi.org/10.1590/S1679-4974202000... For the purposes of this article, the study population was comprised of people aged 18 or over.

Health service use was analyzed through three outcomes: seeking health services in the last 15 days (excluding dental services), medical consultation and hospitalization, both in the last 12 months. The seeking health services and hospitalization outcomes were assessed dichotomously (yes; no), while medical consultations in the last 12 months, were assessed through the following question: When did you last consult a doctor? With the answer option being (i) up to one year ago, (ii) more than one year and less than two years ago, (iii) more than two years and less than three years ago, (iv) more than three years ago and (v) never consulted a doctor. Affirmative answers to item (i) were classified as “yes” and options (ii, iii, iv and v) were classified as “no”.

Exposure was assessed by asking the question: Has a doctor ever diagnosed you as having ...? Except for chronic back problems, which were assessed by asking the question: Do you have a chronic back problem, such as chronic back or neck pain, low back pain, sciatica, vertebrae or disc problems? ¹³13 Ministério da Saúde (BR). Questionários – PNS [Internet]. Brasília: Ministério da Saúde, c2021[citado 2023 Mar 16]. Disponível em: https://www.pns.icict.fiocruz.br/questionarios/.
https://www.pns.icict.fiocruz.br/questio... The number of morbidities was counted based on the following morbidities: chronic back problem (chronic back or neck pain, low back pain, sciatica, vertebrae or disc problems), arthritis or rheumatism, cancer, diabetes, asthma or asthmatic bronchitis, hypertension (excluding hypertension when only during pregnancy), heart disease (heart attack, angina, heart failure or other), chronic kidney failure, depression and work-related musculoskeletal disorders (WMSDs). All self-reported morbidities had a weight of 1 in the morbidity count. Multimorbidity was defined by the presence of two or more self-reported morbidities.

The sociodemographic characteristics analyzed were: sex (female; male), age categorized in years (18-29; 30-39; 40-49; 50-59; 60-69; ≥ 70), education (no education; incomplete elementary education; complete elementary education; incomplete high school education; complete high school education; incomplete higher education; complete higher education) and self-reported race/skin color (White; mixed race; Black; Asian; Indigenous).

The variables related to health services were: having health insurance (yes; no) and being registered with Family Health Strategy (FHS) teams (yes; no). Health needs were assessed through self-rated state of health (very good; good; fair; poor; very poor) and limitation of habitual activities in the last 15 days (yes; no).

Prevalence rates and 95% confidence intervals (95%CI) were estimated for each health service use outcome, stratified by multimorbidity and according to the independent variables.

Crude and adjusted Poisson regression models were used to estimate the measures of effect, prevalence ratios (PR) and their respective 95%CI. The models were adjusted for the independent variables for each health service use and multimorbidity outcome. In the general population, the use of health services is strongly motivated by the person’s sex.¹⁵15 Cobo B, Cruz C, Dick PC. Desigualdades de gênero e raciais no acesso e uso dos serviços de atenção primária à saúde no Brasil. Cien Saude Colet.; 2021;26(9):4021-32. doi: 10.1590/1413-81232021269.05732021.
https://doi.org/10.1590/1413-81232021269... ,¹⁶16 Pilotto LM, Celeste RK. Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998-2013. CadSaude Publica. 2018;34(4):e00052017. doi: 10.1590/0102-311X00052017.
https://doi.org/10.1590/0102-311X0005201... As such, the analyses were stratified by sex.

Surveys that use complex sampling have different probabilities of selecting individuals and clusters. The survey module of the Stata SE software version 15.0 was used to perform the analyses, taking into account the sampling parameters and weights of the individuals.

The PNS was approved by the National Research Ethics Commission (Process No. 3.529.376, dated August 23, 2019). A consent form was signed by all participants at the time of the interview. The data relating to the PNS are publicly accessible, made available electronically by the IBGE, and preserve the identity of the survey participants. The data were extracted and analyzed in July 2022.

RESULTS

Of the 81,768 individuals included in the study, 53.2% were female, 22.8% were between 18 and 29 years of age, the majority were Black and of mixed race (54.3%), and 29.6% reported having completed high school. Of the population assessed, 27% had health insurance and 61.5% were registered with a Family Health Strategy team. Regarding the health of the population, 52.7% self-rated their health as good and 8.5% reported that their habitual activities had been limited in the last 15 days.

Prevalence of multimorbidity was 24.1% (95%CI 23.6;24.7). We found that 22.1% (95%CI 21.6;22.7) reported having sought some sort of health service in the last 15 days, 80.7% (95%CI 80.2;81.1) had had a medical consultation in the last 12 months and 7.6% (95%CI 7.2;8.0) had been hospitalized in the last 12 months.

Prevalence of seeking health services in the last 15 days was 37.8% (95%CI 36.6;39.0) among individuals with multimorbidity and 40.1% among females (95%CI 38.7;41.5). Among individuals with multimorbidity, prevalence of seeking health services was higher among those with incomplete higher education (44.8%; 95%CI 37.6;52.2) and complete higher education (42.9; 95%CI 39.6;46.3), compared to those with less education. Higher prevalence of seeking health services was found among individuals with multimorbidity, those who had health insurance (42.4%; 95%CI 40.0;44.8), those who self-rated their state of health as very poor (53.6%; 95%CI 47.6;59.5) and among those who reported some limitation of habitual activities in the last 15 days (65.7%; 95%CI 63.4;68.0) (Table 1).

Among people with multimorbidity, prevalence of consultations in the last year was 94.9%, while it was 78.8% for individuals without multimorbidity. Among individuals with multimorbidity, prevalence of having medical consultations in the last year was higher among females (95.8%; 95%CI 95.1;96.3), among people aged 60 to 69 years (96.5%; 95%CI 95.7;97.2), those with health insurance (97.5%; 95%CI 96.7;98.0), those who self-rated their state of health as very poor (95.9%; 95%CI 91.2;98.1) and those whose habitual activities had been limited (97.7%; 95%CI 96.7;98.3) (Table 1).

Prevalence of hospitalizations in the last year among individuals with multimorbidity was 14%, while it was 6% among those without multimorbidity. Hospitalizations in the last year among individuals with multimorbidity were more frequent among people aged 30 to 39 years (16.7%; 95%CI 12.9;21.4) and who had no education (19.7%; 95%CI 17.1;22.6). Prevalence of hospitalization among people with multimorbidity showed an inverse relationship with self-rated state of health, being 7.5% (95%CI 5.0;11.0) among those with very good self-rated health and 30.3% (95%CI 25.3;35.9) for those with very poor self-rated health (Table 1).

Table 2 shows the crude and adjusted analysis of association between multimorbidity and use of health services (seeking health services, medical consultations and hospitalizations) for the general population and stratified by sex. The adjusted model showed significant association between multimorbidity and use of services. Prevalence of seeking health services was 38% higher among people with multimorbidity compared to those who did not have multimorbidity, in the general population (PR = 1.38; 95%CI 1.31;1.45). Regarding the sex of the participants, seeking health services, among those with multimorbidity, was 46% for males (PR = 1.46; 95%CI 1.34;1.60) and 38% for females (PR = 1.38; 95%CI 1.30;1.46).

Among individuals with multimorbidity, prevalence of medical consultations in the last 12 months was 11% higher (95%CI 1.10;1.12), compared to those without multimorbidity. In the case of males, prevalence of medical consultations was higher among individuals with multimorbidity (PR = 1.17; 95%CI 1.15;1.18) than for females (PR = 1.09; 95%CI 1.07;1.10), compared to those who did not have multimorbidity. Finally, prevalence of hospitalizations among individuals with multimorbidity was 56% higher (95%CI 1.44;1.70), compared to people without multimorbidity. The prevalence of hospitalizations in the last 12 months, for those with multimorbidities, were 74% higher among females (PR = 1.74; 95%CI 1.52;2.00) and 47% higher among males (PR = 1.47 ; 95%CI 1.22;1.79) (Table 2).

DISCUSSION

This article identified association of multimorbidity with use of health services, being greater among males for medical consultations. Among individuals with multimorbidity, seeking health services in the last 15 days and hospitalizations in the last 12 months were twice as high, compared to individuals without multimorbidity. Prevalence of having medical consultations in the last 12 months was 20% higher among those with multimorbidity.

The study conducted by Shi et. al. (2021)¹¹11 Shi X, Lima SMS, Mota CMM, Lu Y, Stafford RS, Pereira CV. Prevalence of multimorbidity of chronic noncommunicable diseases in Brazil: population-based study. JMIR Public Health Surveill. 2021;7(11):e29693. doi: 10.2196/29693.
https://doi.org/10.2196/29693... found that the demand for health services and hospitalizations was greater among individuals with multimorbidity between 1998 and 2013, in Brazil. The results of our study point to continued greater use of a variety of health services in Brazil, in 2019, among people with multimorbidity, emphasizing the need for expanded discussions on the provision of services for this population.

A study using data from the 2013 PNS found that prevalence of multimorbidity was 22.2%, based on a list of diseases similar to that used in our study. In the former study, 16.6% of the population had sought health services in the 15 days prior to the survey, 71.8% had had medical consultations and 6.6% had been hospitalized in the last 12 months.⁷7 Souza ASS, Braga JU. Trends in the use of health services and their relationship with multimorbidity in Brazil, 1998-2013. BMC Health Serv Res. 2020;20(1):1080. doi: 10.1186/s12913-020-05938-4.
https://doi.org/10.1186/s12913-020-05938... The findings for 2019 show a slight increase in the use of healthcare services in recent years.

A recent systematic review estimated combined global prevalence of multimorbidity to be 33.1%. That review included 70 studies, which had analyzed 37 high-income countries and 35 low- and middle-income countries, from 1992 to 2017. In high-income countries estimated prevalence of multimorbidity was 37.9% , while in low- and middle-income countries it was 29.7%.¹⁷17 Nguyen H, Manolova G, Daskalopoulou C, Vitoratou S, Prince M, Prina AM. Prevalence of multimorbidity in community settings: a systematic review and meta-analysis of observational studies. J Comorb. 2019;9:1-15. doi: 10.1177/2235042X19870934.
https://doi.org/10.1177/2235042X19870934... However, it is still unclear whether there is geographic variation in the prevalence of multimorbidity or whether these differences can be simply explained by differences in diagnostic and data management systems between countries with different income levels.¹⁷17 Nguyen H, Manolova G, Daskalopoulou C, Vitoratou S, Prince M, Prina AM. Prevalence of multimorbidity in community settings: a systematic review and meta-analysis of observational studies. J Comorb. 2019;9:1-15. doi: 10.1177/2235042X19870934.
https://doi.org/10.1177/2235042X19870934...

In our study, among individuals with multimorbidity, seeking health services was higher among younger people. Although multimorbidity has higher prevalence in older age groups, in Brazil people develop morbidities and multimorbidity at a younger age than people in wealthier countries.⁵5 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43. doi: 10.1016/S0140-6736(12)60240-2.
https://doi.org/10.1016/S0140-6736(12)60... ,⁶6 Rzewuska M, Azevedo-Marques JM, Coxon D, Zanetti ML, Zanetti AC, Franco LJ, et al. Epidemiology of multimorbidity within the Brazilian adult general population: evidence from the 2013 National Health Survey (PNS 2013). PLoS One. 2017;12(2):e0171813. doi: 10.1371/journal.pone.0171813.
https://doi.org/10.1371/journal.pone.017... ,¹⁸18 Fortin M, Stewart M, Poitras ME, Almirall J, Maddocks H. A systematic review of prevalence studies on multimorbidity: toward a more uniform methodology. Ann Fam Med. 2012;10(2):142-51. doi: 10.1370/afm.1337.
https://doi.org/10.1370/afm.1337... Being female and being an older adult are the factors that most bear influence on the population using health services.¹⁹19 Capilheira MF, Santos IS. Fatores individuais associados à utilização de consultas médicas por adultos. Rev Saude Publica. 2006;40(3):436-43. doi: 10.1590/s0034-89102006000300011.
https://doi.org/10.1590/s0034-8910200600... ,²⁰20 Dias-da-Costa JS, Facchini LA. Use of outpatient services in an urban area of Southern Brazil: place and frequency. Rev Saude Publica. 1997;31(4):360-9.

Prevalence of consultations was higher among people with multimorbidity compared to individuals without multimorbidity. However, among individuals with multimorbidity, prevalence of health service use does not differ much between sociodemographic characteristics, access and health needs. In the general population, health services are more used by women, people with a higher level of education and those with health insurance.¹⁶16 Pilotto LM, Celeste RK. Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998-2013. CadSaude Publica. 2018;34(4):e00052017. doi: 10.1590/0102-311X00052017.
https://doi.org/10.1590/0102-311X0005201... However, a study conducted in Serbia,²¹21 Jankovic J, Mirkovic M, Jovic-Vranes A, Santric-Milicevic M, Terzic-Supic Z. Association between non-communicable disease multimorbidity and health care utilization in a middle-income country: population-based study. Public Health. 2018;155:35-42. doi: 10.1016/j.puhe.2017.11.014.
https://doi.org/10.1016/j.puhe.2017.11.0... in 2013, found that having multimorbidity reduced differences in the prevalence of medical consultations with regard to these variables, indicating a possible reduction in differences in the use of health services among people with health needs, such as people with multimorbidity.

Some studies indicate that, although the underlying reasons for association found between education, deprivation and multimorbidity are probably complex and multifactorial, intermediary factors such as lifestyle, access to and use of health services and neighborhood context are also important.²²22 Pathirana TI, Jackson CA. Socioeconomic status and multimorbidity: a systematic review and meta-analysis. Aust N Z J Public Health. 2018;42(2):186-94. doi: 10.1111/1753-6405.12762.
https://doi.org/10.1111/1753-6405.12762... ,²³23 Wang HHX, Wang JJ, Wong SYS, Wong MCS, Li FJ, Wang PX, et al. Epidemiology of multimorbidity in China and implications for the healthcare system: cross-sectional survey among 162,464 community household residents in southern China. BMC Med. 2014;12:188. doi: 10.1186/s12916-014-0188-0.
https://doi.org/10.1186/s12916-014-0188-... Social inequities are revealed through the positive relationship between multimorbidity and poorer socioeconomic indicators, pointing to the challenge to be faced by health systems in promoting this population’s access to health services.⁵5 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43. doi: 10.1016/S0140-6736(12)60240-2.
https://doi.org/10.1016/S0140-6736(12)60...

Even after progressive adjustment of sociodemographic characteristics, access and health needs, having multimorbidity increased the use of health services, with greater influence for the male sex for medical consultations. These findings corroborate the results of studies previously carried out in Brazil (2020),⁷7 Souza ASS, Braga JU. Trends in the use of health services and their relationship with multimorbidity in Brazil, 1998-2013. BMC Health Serv Res. 2020;20(1):1080. doi: 10.1186/s12913-020-05938-4.
https://doi.org/10.1186/s12913-020-05938... China (2014),²³23 Wang HHX, Wang JJ, Wong SYS, Wong MCS, Li FJ, Wang PX, et al. Epidemiology of multimorbidity in China and implications for the healthcare system: cross-sectional survey among 162,464 community household residents in southern China. BMC Med. 2014;12:188. doi: 10.1186/s12916-014-0188-0.
https://doi.org/10.1186/s12916-014-0188-... Ireland (2011),²⁴24 Glynn LG, Valderas JM, Healy P, Burke E, Newell J, Gillespie P, et al. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract. 2011;28(5):516-23. doi: 10.1093/fampra/cmr013.
https://doi.org/10.1093/fampra/cmr013... and the Netherlands (2014),²⁵25 van Oostrom SH, Picavet HSJ, Bruin SR, Stirbu I, Korevaar JC, Schellevis FG, et al. Multimorbidity of chronic diseases and health care utilization in general practice. BMC Fam Pract. 2014;15:61. doi: 10.1186/1471-2296-15-61.
https://doi.org/10.1186/1471-2296-15-61... demonstrating an increase in primary and secondary care use associated with multimorbidity, even when controlling for age, sex and social status.

The limitations of this study include the use of self-reported measures of morbidity and health services that may underestimate their prevalence.²2 Diederichs C, Berger K, Bartels DB. The measurement of multiple chronic diseases–a systematic review on existing multimorbidity indices. J Gerontol A Biol Sci Med Sci. 2011;66(3):301-11. doi: 10.1093/gerona/glq208.
https://doi.org/10.1093/gerona/glq208... ,¹⁸18 Fortin M, Stewart M, Poitras ME, Almirall J, Maddocks H. A systematic review of prevalence studies on multimorbidity: toward a more uniform methodology. Ann Fam Med. 2012;10(2):142-51. doi: 10.1370/afm.1337.
https://doi.org/10.1370/afm.1337... However, in population-based studies, self-reported information is considered valid and robust for monitoring the health situation.²⁶26 Malta DC, Stopa SR, Andrade SSCA, Szwarcwald CL, Silva Júnior JB, Reis AAC. Cuidado em saúde em adultos com hipertensão arterial autorreferida no Brasil segundo dados da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol. 2015;18(Supl 2):109-22. doi: 10.1590/1980-5497201500060010.
https://doi.org/10.1590/1980-54972015000... ,²⁷27 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2021: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2022. Furthermore, this study considered all diseases equally, although the effect of multimorbidity on individuals may vary depending on chronic noncommunicable disease (NCDs) combination and severity.⁵5 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43. doi: 10.1016/S0140-6736(12)60240-2.
https://doi.org/10.1016/S0140-6736(12)60... It is important to highlight that our multimorbidity classification only used the set of ten health conditions, which may have led to it being underestimated among the study population. Variability in the number of health conditions included in multimorbidity classification measures makes it difficult to compare prevalence and its impact across populations.²2 Diederichs C, Berger K, Bartels DB. The measurement of multiple chronic diseases–a systematic review on existing multimorbidity indices. J Gerontol A Biol Sci Med Sci. 2011;66(3):301-11. doi: 10.1093/gerona/glq208.
https://doi.org/10.1093/gerona/glq208... ,²⁸28 Salive ME. Multimorbidity in older adults. Epidemiol Rev. 2013;33:75-83. doi: 10.1093/epirev/mxs009.
https://doi.org/10.1093/epirev/mxs009... Another important limitation related to the cross-sectional study design is reverse causality. Temporality between medical diagnosis and seeking health services cannot be defined, therefore, the results must be interpreted paying attention to the possible overestimation of the measures of effect between exposure and outcome, given that for presence/absence of morbidity to be self-reported, diagnosis by a health professional is necessary, implying the use of health services.

Among its strengths, this study used nationwide data, enabling the generalization of its results to the entire Brazilian population and even to countries with equivalent characteristics. Furthermore, periodic surveys may provide important information for monitoring the use of health services among this population.

In conclusion, this study showed that people with multimorbidity used health services more, regardless of the type of service, considering that they can often be attended to by several health professionals, given the cross-cutting format of service provision and health policies that currently exist for the care of people with NCDs. In this sense, health care policies and care provision actions focused on access to health services must be developed for this population, breaking the traditional and cross-cutting approaches to specialist care, transforming them into actions focused on the health service user and not on their individual diseases.

Care for chronic conditions requires much more complex care models, in which the focus is not on response time depending on risks, but on continuity of care without its being fragmented.²⁹29 Mendes EV. O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da estratégia da saúde da família [Internet]. Brasília: Organização Pan-Americana de Saúde; 2012 [citado 2023 Abr 28]. 512 p. Disponível em: http://www.conass.org.br/biblioteca/o-cuidado-das-condicoes-cronicas-na-atencao-primaria-a-saude/.
http://www.conass.org.br/biblioteca/o-cu... In this sense, prospective studies can help to deepen knowledge about the causal relationship between multimorbidity patterns and their relationship with health services, as well as the creation of more efficient care models, thus seeking to increase the quality of care provided to this population.

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