title: Non communicable disease multimorbidity and associated health care utilization and expenditures in India: cross-sectional study.
abstract: BACKGROUND
  Non communicable disease (NCD) multimorbidity is increasingly becoming common in high income settings but little is known about its epidemiology and associated impacts on citizens and health systems in low and middle-income countries (LMICs). We aim to examine the socio-demographic distribution of NCD multimorbidity (≥2 diseases) and its implications for health care utilization and out-of-pocket expenditure (OOPE) in India.
  
  
  METHODS
  We analyzed cross-sectional nationally representative data from the World Health Organisaion Study on Global Ageing and Adult Health (WHO-SAGE), conducted in India during 2007. Multiple logistic regression was used to determine socio-demographic predictors of self-reported multimorbidity. A two part model was used to assess the relationship between number of NCDs and health care utilization including OOPE.
  
  
  RESULTS
  28.5% of the sample population had at least one NCD and 8.9% had NCD multimorbidity. The prevalence of multimorbidity increased from 1.3% in 18-29 year olds to 30.6% in those aged 70 years and above. Mean outpatient visits in the preceding 12 months increased from 2.2 to 6.2 and the percentage reporting an overnight hospital stay in the past 3 years increased from 9% to 29% in those with no NCD and ≥2 NCDs respectively (p <0.001).OOPE incurred during the last outpatient visit increased from INR 272.1 (95% CI = 249.0-295.2) in respondents with no NCDs to INR 454.1 (95% CI = 407.8-500.4) in respondents with ≥2 NCDs. However, we did not find an increase in OOPE during the last inpatient visit with number of NCDs (7865.9 INR for those with zero NCDs compared with 7301.3 for those with ≥2 NCDs). For both outpatient and inpatient OOPE, medicine constitutes the largest proportion of spending (70.7% for outpatient, 53.6% for inpatient visit), followed by spending for health care provider (14.0% for outpatient, 12.2% for inpatient visit).
  
  
  CONCLUSIONS
  NCD multimorbidity is common in the Indian adult population and is associated with substantially higher healthcare utilization and OOPE. Strategies to address the growing burden of NCDs in LMICs should include efforts to improve the management of patients with multimorbidity and reduce associated financial burden to individuals and households.
authors.affiliation: Indian Institute of Public Health-Bhubaneswar, Public Health Foundation of India, 2nd and 3rd Floor, JSS Software Technology Park, E1/1, Infocity Road, Patia, Bhubaneswar, Odisha, India. sanghamitra.pati@iiphb.org.
authors.forename: Sanghamitra
authors.initials: S
authors.lastname: Pati
authors.forename: Sutapa
authors.initials: S
authors.lastname: Agrawal
authors.forename: Subhashisa
authors.initials: S
authors.lastname: Swain
authors.forename: John Tayu
authors.initials: JT
authors.lastname: Lee
authors.forename: Sukumar
authors.initials: S
authors.lastname: Vellakkal
authors.forename: Mohammad Akhtar
authors.initials: MA
authors.lastname: Hussain
authors.forename: Christopher
authors.initials: C
authors.lastname: Millett
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002908:Chronic Disease / Q000191:economics*; D015897:Comorbidity; D003430:Cross-Sectional Studies; D005260:Female; D005382:Financing, Personal; D005102:Health Expenditures; D006296:Health Services / Q000706:statistics & numerical data*; D006801:Humans; D007194:India; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D055815:Young Adult