title: Co-occurrence of diabetes, myocardial infarction, stroke, and cancer: quantifying age patterns in the Dutch population using health survey data.
abstract: BACKGROUND
  The high prevalence of chronic diseases in Western countries implies that the presence of multiple chronic diseases within one person is common. Especially at older ages, when the likelihood of having a chronic disease increases, the co-occurrence of distinct diseases will be encountered more frequently. The aim of this study was to estimate the age-specific prevalence of multimorbidity in the general population. In particular, we investigate to what extent specific pairs of diseases cluster within people and how this deviates from what is to be expected under the assumption of the independent occurrence of diseases (i.e., sheer coincidence).
  
  
  METHODS
  We used data from a Dutch health survey to estimate the prevalence of pairs of chronic diseases specified by age. Diseases we focused on were diabetes, myocardial infarction, stroke, and cancer. Multinomial P-splines were fitted to the data to model the relation between age and disease status (single versus two diseases). To assess to what extent co-occurrence cannot be explained by independent occurrence, we estimated observed/expected co-occurrence ratios using predictions of the fitted regression models.
  
  
  RESULTS
  Prevalence increased with age for all disease pairs. For all disease pairs, prevalence at most ages was much higher than is to be expected on the basis of coincidence. Observed/expected ratios of disease combinations decreased with age.
  
  
  CONCLUSIONS
  Common chronic diseases co-occur in one individual more frequently than is due to chance. In monitoring the occurrence of diseases among the population at large, such multimorbidity is insufficiently taken into account.
authors: Expertise Centre for Methodology and Information Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands. pieter.van.baal@rivm.nl.
authors: Pieter H
authors: PH
authors: van Baal
authors: Peter M
authors: PM
authors: Engelfriet
authors: Hendriek C
authors: HC
authors: Boshuizen
authors: Jan
authors: J
authors: van de Kassteele
authors: Francois G
authors: FG
authors: Schellevis
authors: Rudolf T
authors: RT
authors: Hoogenveen