title: The effect of comorbidity on health-related quality of life for injury patients in the first year following injury: comparison of three comorbidity adjustment approaches.
abstract: BACKGROUND
  Three approaches exist to deal with the impact of comorbidity in burden of disease studies - the maximum limit approach, the additive approach, and the multiplicative approach. The aim of this study was to compare the three comorbidity approaches in patients with temporary injury consequences as well as comorbid chronic conditions with nontrivial health impacts.
  
  
  METHODS
  Disability weights were assessed using data from the EQ-5D instrument developed by the EuroQol Group and derived from a postal survey among 2,295 injury patients at 2.5 and 9 months after being treated at an emergency department. We compared the observed and predicted EQ-5D disability weights in comorbid cases using data from injury patients with and without comorbidity who were restored from their injuries at 9 months follow-up. The predicted disability weights were calculated using the maximum limit approach, additive approach, and multiplicative approach. The intraclass correlation coefficient (ICC) was used to test whether the values of the observed disability weights and the three model-predicted disability weights were correlated.
  
  
  RESULTS
  The EQ-5D disability weight of injury patients increased significantly with the number of comorbid diseases. The ICCs of the additive, multiplicative, and maximum limit models were 0.817, 0.778, and 0.674, respectively. Although the 95% confidence intervals of the ICCs of the three models overlap, the maximum limit model seems to fit less well than the additive and multiplicative models. For mild to moderate chronic disease (disability weight below 0.21), the association between predicted and observed disability weights was low.
  
  
  CONCLUSIONS
  Comorbidity has a high impact on disability measured with EQ-5D. Ignoring the effect of comorbidity restricts the use of the burden of disease concept in multimorbid populations. Gains from health care or interventions may be easily overestimated if a substantial number of patients suffer from additional conditions. The results of this study found that in accounting for comorbidity effects, all three models showed a strong association between the predicted and observed morbid disability weight, though the maximum limit model seems to fit less well than the additive and multiplicative models. The three models do not fit well in the case of mild to moderate pre-existing disease.
authors.affiliation: Department of Public Health, Erasmus Medical Center, Erasmus University Rotterdam, P,O, Box 1738, 3000 CA, Rotterdam, The Netherlands. j.haagsma@erasmusmc.nl.
authors.forename: Juanita A
authors.initials: JA
authors.lastname: Haagsma
authors.forename: Ed F
authors.initials: EF
authors.lastname: van Beeck
authors.forename: Suzanne
authors.initials: S
authors.lastname: Polinder
authors.forename: Hidde
authors.initials: H
authors.lastname: Toet
authors.forename: Martien
authors.initials: M
authors.lastname: Panneman
authors.forename: Gouke J
authors.initials: GJ
authors.lastname: Bonsel