title: Comorbidity: implications for the importance of primary care in 'case' management.
abstract: BACKGROUND
  Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions.
  
  
  METHODS
  Data from claims on the nonelderly were classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions.
  
  
  RESULTS
  Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions.
  
  
  CONCLUSIONS
  In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients' overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.
authors.affiliation: Department of Health Policy and Management, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD 21205, USA. bstarfie@jhsph.edu
authors.forename: Barbara
authors.initials: B
authors.lastname: Starfield
authors.forename: Klaus W
authors.initials: KW
authors.lastname: Lemke
authors.forename: Terence
authors.initials: T
authors.lastname: Bernhardt
authors.forename: Steven S
authors.initials: SS
authors.lastname: Foldes
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Forrest
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Weiner
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D019090:Case Management / Q000706:statistics & numerical data*; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease / Q000453:epidemiology*; D015897:Comorbidity; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008511:Medicine / Q000706:statistics & numerical data; D008875:Middle Aged; D008910:Minnesota / Q000453:epidemiology; D009819:Office Visits; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013038:Specialization