title: Reducing complexity: a visualisation of multimorbidity by combining disease clusters and triads.
abstract: BACKGROUND
  Multimorbidity is highly prevalent in the elderly and relates to many adverse outcomes, such as higher mortality, increased disability and functional decline. Many studies tried to reduce the heterogeneity of multimorbidity by identifying multimorbidity clusters or disease combinations, however, the internal structure of multimorbidity clusters and the linking between disease combinations and clusters are still unknown. The aim of this study was to depict which diseases were associated with each other on person-level within the clusters and which ones were responsible for overlapping multimorbidity clusters.
  
  
  METHODS
  The study analyses insurance claims data of the Gmünder ErsatzKasse from 2006 with 43,632 female and 54,987 male patients who were 65 years and older. The analyses are based on multimorbidity clusters from a previous study and combinations of three diseases ("triads") identified by observed/expected ratios ≥ 2 and prevalence rates ≥ 1%. In order to visualise a "disease network", an edgelist was extracted from these triads, which was analysed by network analysis and graphically linked to multimorbidity clusters.
  
  
  RESULTS
  We found 57 relevant triads consisting of 31 chronic conditions with 200 disease associations ("edges") in females and 51 triads of 29 diseases with 174 edges in males. In the disease network, the cluster of cardiovascular and metabolic disorders comprised 12 of these conditions in females and 14 in males. The cluster of anxiety, depression, somatoform disorders, and pain consisted of 15 conditions in females and 12 in males.
  
  
  CONCLUSIONS
  We were able to show which diseases were associated with each other in our data set, to which clusters the diseases were assigned, and which diseases were responsible for overlapping clusters. The disease with the highest number of associations, and the most important mediator between diseases, was chronic low back pain. In females, depression was also associated with many other diseases. We found a multitude of associations between disorders of the metabolic syndrome of which hypertension was the most central disease. The most prominent bridges were between the metabolic syndrome and musculoskeletal disorders. Guideline developers might find our approach useful as a basis for discussing which comorbidity should be addressed.
authors.affiliation: Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistr, 52, Hamburg 20246, Germany. in.schaefer@uke.de.
authors.forename: Ingmar
authors.initials: I
authors.lastname: Schäfer
authors.forename: Hanna
authors.initials: H
authors.lastname: Kaduszkiewicz
authors.forename: Hans-Otto
authors.initials: HO
authors.lastname: Wagner
authors.forename: Gerhard
authors.initials: G
authors.lastname: Schön
authors.forename: Martin
authors.initials: M
authors.lastname: Scherer
authors.forename: Hendrik
authors.initials: H
authors.lastname: van den Bussche
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000453:epidemiology; D002908:Chronic Disease / Q000453:epidemiology*; D016000:Cluster Analysis; D015897:Comorbidity; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D007345:Insurance Claim Review / Q000706:statistics & numerical data; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology; D008659:Metabolic Diseases / Q000453:epidemiology; D015995:Prevalence