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OBJECTIVE: Map multimorbidity-weighted index (MWI) conditions to International Classification of Diseases, 10th Revision (ICD-10), expand the conditions and codes to develop a new ICD-10-coded MWI (MWI-ICD10) and updated MWI-ICD9, and assess their consistency. DESIGN: Population-based retrospective cohort. SETTING: Large medical centre between 2013 and 2017. PARTICIPANTS: Adults ≥18 years old with encounters in each of 4 years (2013, 2014, 2016, 2017). MAIN OUTCOME MEASURES: MWI conditions mapped to ICD-10 codes, and additional conditions and codes added to produce a new MWI-ICD10 and updated MWI-ICD9. We compared the prevalence of ICD-coded MWI conditions within the ICD-9 era (2013-2014), within the ICD-10 era (2016-2017) and across the ICD-9-ICD-10 transition in 2015 (washout period) among adults present in both sets of comparison years. We computed the prevalence and change in prevalence of conditions when using MWI-ICD10 versus MWI-ICD9. RESULTS: 88 175 adults met inclusion criteria. Participants were 60.8% female, 50.5% white, with mean age 54.7±17.3 years and baseline MWI-ICD9 4.47±6.02 (range 0-64.33). Of 94 conditions, 65 had

BackgroundOlder multimorbid adults have a high risk of mortality and a short life expectancy (LE). Providing high-value care and avoiding care overuse, including of preventive care, is a serious challenge among multimorbid patients. While guidelines recommend to tailor preventive care according to the estimated LE, there is no tool to estimate LE in this specific population. Our objective is therefore to develop an LE estimator for older multimorbid adults by transforming a mortality prognostic index, which will be developed and internally validated in a prospective cohort.Methods and analysisWe will analyse data of the Optimising Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older People cohort study in Bern, Switzerland. 822 participants were included at hospitalisation with age of 70 years or older, multimorbidity (three or more chronic medical conditions) and polypharmacy (use of five drugs or more for >30 days). All-cause mortality will be assessed during 3 years of follow-up. We will apply a flexible parametric survival model with backward stepwise selection to identify the mortality risk predictors. The model will be internally validated using bootstrapping techniques. We will derive a point-based risk score from the regression coefficients. We will transform the 3-year mortality prognostic index into an LE estimator using the Gompertz survival function. We will perform a qualitative assessment of the clinical usability of the LE estimator and its application. We will conduct the development and validation of the mortality prognostic index following the Prognosis Research Strategy (PROGRESS) framework and report it following the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) statement.Ethics and disseminationWritten informed consent by patients themselves or, in the case of cognitive impairment, by a legal representative, was required before enrolment. The local ethics committee (Kantonale Ethikkommission Bern) has approved the study. We plan to publish the results in peer-reviewed journals and present them at national and international conferences.

Introduction: Understanding causal risk factors that contribute to the development of multimorbidity is essential for designing and targeting effective preventive strategies. Despite a large body of research in this field, there has been little critical discussion about the appropriateness of the various analytical approaches used. This proposed scoping review aims to summarise and appraise the analytical approaches used in the published literature that evaluated risk factors of multimorbidity and to provide guidance for researchers conducting analyses in this field., Methods and Analysis: We will systematically search three electronic databases-Embase, Global Health and MEDLINE, as well as the reference lists of identified relevant review articles, from inception to September 2024. We will screen titles and abstracts using the artificial intelligence-aided software ASReview, followed by screening for eligible articles in full text and extracting data. We will then categorise the analytical approaches used across studies, provide a comprehensive overview of the methodology and discuss the potential strengths and limitations of each analytical approach., Ethics and Dissemination: We will undertake a secondary analysis of published literature; therefore, ethical approval is not required. The results will be disseminated through an open-access, peer-reviewed publication. This systematic scoping review will serve as a guide for researchers in selecting analytical approaches for aetiological multimorbidity research, thereby improving the quality and comparability of research in this field., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Objective: To investigate how various morbidities affect older patients' performance on the Timed Up and Go (TUG) test., Design: Cross-sectional study., Setting: The seven government hospitals of Lahore, Pakistan, included are major tertiary care centres, representing an older patient population of Punjab, Pakistan., Method: 160 elderly participants completed the TUG test, frailty evaluations and Charlson Comorbidity Index (CCI) scoring to assess mobility, frailty and comorbidity burden. The Student's t-test analysed differences between TUG groups (<10 vs ≥10 s). Multivariate linear regression pinpointed key predictors of CCI scores. All analyses were performed using SPSS software., Results: A total of 160 participants (mean age: 67.2±6.9 years and body mass index (BMI): 28.7±4.9 kg/m²) were included. Those with TUG test times under 10 s had lower CCI scores (5.06±1.8) and frailty index (0.15±0.07), compared with those with longer times (CCI: 8.6±4.3 and frailty index: 0.42±0.1). Multivariate regression analysis revealed that TUG time (β=0.342, p=0.001), frailty index (β=0.680, p=0.003), age (β=0.128, p=0.002) and BMI (β=0.098, p=0.027) were significant predictors of CCI. Additionally, higher Mini-Mental State Examination scores (β=-0.092, p=0.017) were associated with lower comorbidity burden. These results highlight mobility, frailty and cognitive function as a predictors of comorbidities in the elderly., Conclusion: Our study highlights a significant relationship between mobility, frailty and cognitive function with the comorbidity burden in older adults. Incorporating these metrics into routine care can guide targeted interventions, promoting healthier ageing and improved quality of life., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objectives: Multimorbidity has been recognised as a global public health issue, and individuals with multimorbidity have been found to have high healthcare utilisation. This study aims to estimate the prevalence of non-communicable diseases among adults in Malaysia, identify factors associated with multimorbidity, and assess the association between the number of non-communicable diseases and outpatient services utilisation., Design and Setting: A retrospective secondary data analysis using data from the National Health and Morbidity Survey 2019, a cross-sectional household survey among the population in Malaysia., Participants: All adults aged 18 years and above., Outcome Measures: The two outcome variables were multimorbidity and outpatient services utilisation. Characteristics of respondents and those having multimorbidity were described using complex sample descriptive statistics. We used multivariable logistic regression to determine the associated factors of having multimorbidity and the association between the number of non-communicable diseases and outpatient services utilisation., Results: Overall, 11 347 respondents were included in the analysis. This study found a prevalence of 11.4 (95% CI=10.43-12.39) for multimorbidity. Age, marital status and working status were the factors associated with multimorbidity. Adults with multimorbidity were high users of outpatient services (20.4%, 95% CI=17.5-23.7), approximately threefold of adults with no non-communicable diseases. In the final model, multimorbidity showed an adjusted OR of 3.28 (95% CI=2.48-4.32) for outpatient services utilisation., Conclusion: Understanding factors associated with multimorbidity and the magnitude of the impact of having multimorbidity towards outpatient services utilisation could help in future planning for healthcare system transformation. The recently launched Health White Paper for Malaysia has emphasised primary healthcare as a critical component to achieve aspirations of the health system, which includes equity and responsiveness. Strengthening primary care services and improving patient navigation across healthcare levels are critical to supporting individuals with multimorbidity. Avenues for further research include exploring a wider range of conditions and assessing the longitudinal impact of multimorbidity on healthcare utilisation and health outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objectives: To map the scope of available evidence on relationships between multimorbidity patterns and functioning among adults in low- and middle-income countries (LMICs), and describe methods used., Design: Scoping review guided by a five-step methodological framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews reporting guidelines., Data Sources: PubMed/MEDLINE, Scopus, EBSCOhost (CINAHL) and Cochrane databases were searched from January 1976 to March 2023, plus reference lists of included studies., Eligibility Criteria for Selecting Studies: Peer-reviewed full-text articles or conference proceedings of any design, published in English or Afrikaans, involving adults (>18 years) with multimorbidity living in LMICs. Studies had to refer to associations between multimorbid patterns of co-occurrence and functioning. Multimorbidity was defined as the coexistence of ≥2 diseases, including any combination of non-communicable, infectious and mental health conditions., Data Extraction and Synthesis: Data were extracted independently by two reviewers using a piloted form. Findings were synthesised according to methodological approaches, multimorbidity-pattern epidemiology, evidence gaps/limitations and recommendations for future research. The International Classification of Functioning, Disability and Health framework was used to classify functional problems., Results: Nine studies (total sample size: 62 003) were included, mainly from upper-middle-income Asian countries. Key methodological inconsistencies were identified in defining and operationalising multimorbidity, conditions included in determining patterns, statistical methods for pattern determination and functioning outcome measures. Five main multimorbidity pattern domains emerged: Cardio-Metabolic and Coronary Atherosclerotic, Musculoskeletal, Respiratory and Digestive/Visceral, Degenerative, and Mental Health-Related. Mobility limitations, instrumental activities of daily living, self-care and bowel/bladder problems were consistently linked to all pattern domains., Conclusions: The limited and geographically skewed body of literature, along with methodological inconsistencies, hampers a comprehensive understanding of multimorbidity patterns and associations with functioning in LMICs. Future research should explore context-specific multimorbidity definitions, employ transparent methodologies, use standardised measures and incorporate diverse samples to inform tailored interventions and policies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objective: Explore the nature and prevalence of long-term conditions in individuals with intellectual disability., Design: Retrospective longitudinal population-based study., Setting: Primary and secondary care data across the population of Wales with the Secure Anonymised Information Linkage (SAIL) Databank., Participants: 14 323 individuals were identified during the study date period 1 January 2000 to 31 December 2021 using the following inclusion criteria: 18 or older, alive at the cohort start date, a resident of Wales, with a primary care registration at a SAIL providing general practice with available records and a recorded diagnosis of intellectual disability. Once individuals were identified, health records were observed from birth., Results: 13 069 individuals had a recorded diagnosis of intellectual disability and at least one long-term condition, reflecting 91.25% of the population. Demographic data from the SAIL dataset reveal that the study population is predominantly White, with low levels of representation of non-White ethnic groups. In the cohort, a larger proportion of patients live in the most deprived areas of Wales (22.30%), with fewer individuals in less deprived categories. Mental illness was identified as the most prevalent of the identified long-term conditions, whereby 30.91% of the population had a recorded diagnosis of a mental illness which was chronic. For many common conditions, including epilepsy, thyroid disorders, upper gastrointestinal disorders, chronic kidney disease and diabetes, there was an overall trend of higher prevalence rates in the intellectual disability cohort when compared with the general population. The prevalence of hypertension was lower in individuals with intellectual disability. Chronic constipation, chronic diarrhoea and insomnia were examples of long-term conditions added as relevant to individuals with intellectual disability. Notable differences in the distribution of long-term conditions were observed when comparing across sex and age groups. The number of long-term conditions increases with age. Conditions which may usually be expected to emerge later in life are present in younger age groups, such as diabetes, hypertension and chronic arthritis. When hospital episodes were analysed, epilepsy, diabetes, chronic airway disease and mental illness were commonly treated conditions during hospital admission across both sexes. Conditions which were less prevalent in the intellectual disability cohort, but which were treated during ≥6% of total hospital admissions include cancer, cardiac arrhythmias and cerebral palsy., Conclusions: This study establishes a range of 40 relevant long-term conditions for people with intellectual disability through an iterative process, which included a review of the available literature and a series of discussions with a Professional Advisory Panel and Patient and Public Involvement groups of this research project. The findings of the study reinforce the high prevalence and early emergence of long-term conditions in the intellectual disability cohort. It also demonstrates the difference in the range of conditions when compared with the general population. There were differences in long-term conditions when separated by sex and age. Long-term conditions which commonly require treatment in hospitals were also revealed. Further work is required to translate the findings of this study into actionable insights. Clusters of multiple long-term conditions, trajectories, outcomes and risk factors should be explored to optimise the understanding and longitudinal care of individuals with intellectual disabilities and long-term conditions., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare: Authors RK, EA, GC, GTJ, NK, AA and SG received financial support from the DECODE funding from UK National Institute for Health and Care Research (NIHR203981) for the submitted work; there are no other declared relationships or activities that could appear to have influenced the submitted work. All other authors do not have any competing interests to declare., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Introduction: There is currently limited information regarding the association between the modified Nutrition Risk in Critically Ill (mNUTRIC) score, nutrition delivery and clinical outcomes in critically ill patients admitted to the intensive care unit (ICU) section., Methods and Analysis: The Isfahan-ICU study is a multicentre, prospective observational cohort study that will be conducted on critically ill adults treated in the trauma or medical ICU sections of six hospitals to investigate whether clinical outcomes, including length of ICU stay and 30-day survival, vary by the mNUTRIC score at admission or the 7-day nutrition delivery. This paper outlines the Isfahan-ICU study protocol approved by the ethics committee of Isfahan University of Medical Sciences, Iran. Patient confidentiality is ensured, and study results will be shared at conferences and in medical papers., Ethics and Dissemination: This study protocol was reviewed and approved by the ethics committee of the Isfahan University of Medical Sciences, Isfahan, Iran (IR.MUI., Research: REC.1401.184). The patient's identity will be considered confidential and will not be revealed or published under any circumstances; all provisions of laws governing personal data protection will be observed. Patient data recorded in the electronic survey will be documented pseudonymously using de-identified patient ID codes, and authorised staff at each participating site will have access to only their identifiable data. Results from the study will be disseminated at national and international conferences and in medical papers., Trial Registration Number: Ethics committee of the Isfahan University of Medical Sciences, Isfahan, Iran (IR.MUI., Research: REC.1401.184)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objectives: Proton pump inhibitors (PPIs) are widely prescribed medications and commonly used for the treatment of gastric acid-related disorders. Nevertheless, PPIs are often overused leading to potential adverse effects and unnecessary healthcare costs. Deprescribing strategies have emerged to safely reduce or substitute inappropriate PPIs and optimise patient care in an evidence-based manner. This protocol describes a study to evaluate the effectiveness of a PPI deprescribing intervention in comparison to usual care in the Swiss primary care setting., Design: An open-label, cluster randomised controlled trial., Setting: Swiss primary care settings., Participants: Included participants will be adults with inappropriate PPI treatment and will be recruited by general practitioners (GPs). Participants treated by the same GP constitute a cluster. Clusters are randomised 1:1 to either the intervention group or the control group., Interventions: The intervention components consist of deprescribing tools including educational material, decision aids for both participants and GPs, and additional trainings for GPs only. Patients in the control group will receive usual care. Data will be collected at baseline, 3-, 6-, 9- and 12-month follow-up time through online surveys or a phone call for both GPs and participants., Primary and Secondary Outcome Measures: The first co-primary endpoint is the effectiveness of the deprescribing intervention measured by the change of prescribed PPI dose. The second co-primary endpoint is safety, which is measured with the Reflux Disease Questionnaire assessing change in gastrointestinal symptoms. There are several secondary endpoints, such as the total number of prescribed medications, occurrences of changes in prescription patterns, PPI discontinuation and cost-effectiveness., Conclusions: The findings from this study will provide evidence on the effectiveness and safety of a PPI deprescribing intervention for patients and GPs. Successful implementation of our PPI deprescribing strategy has the potential to improve patient outcomes and lower costs., Trial Registration Number: NCT06129474., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Purpose: We have established the SAIL MELD-B electronic cohort (e-cohort SMC) and the SAIL MELD-B children and Young adults e-cohort (SMYC) as a part of the Multidisciplinary Ecosystem to study Lifecourse Determinants and Prevention of Early-onset Burdensome Multimorbidity (MELD-B) project. Each cohort has been created to investigate and develop a deeper understanding of the lived experience of the 'burdensomeness' of multimorbidity by identifying new clusters of burdensomeness concepts, exploring early life risk factors of multimorbidity and modelling hypothetical prevention scenarios., Participants: The SMC and SMYC are longitudinal e-cohorts created from routinely collected individual-level population-scale anonymised data sources available within the Secure Anonymised Information Linkage (SAIL) Databank. They include individuals with available records from linked health and demographic data sources in SAIL at any time between 1 January 2000 and 31 December 2022. The SMYC e-cohort is a subset of the SMC, including only individuals born on or after the cohort start date., Findings to Date: The SMC and SMYC cohorts include 5 180 602 (50.3% female and 49.7% male) and 896 155 (48.7% female and 51.3% male) individuals, respectively. Considering both primary and secondary care health data, the five most common long-term conditions for individuals in SMC are 'Depression', affecting 21.6% of the cohort, 'Anxiety' (21.1%), 'Asthma' (17.5%), 'Hypertension' (16.2%) and 'Atopic Eczema' (14.1%) and the five most common conditions for individuals in SMYC are 'Atopic Eczema' (21.2%), 'Asthma' (11.6%), 'Anxiety' (6.0%), 'Deafness' (4.6%) and 'Depression' (4.3%)., Future Plans: The SMC and SMYC e-cohorts have been developed using a reproducible, maintainable concept curation pipeline, which allows for the cohorts to be updated dynamically over time and manages for the request and processing of further approved long-term conditions and burdensomeness concepts extraction. Best practices from the MELD-B project can be utilised across other projects, accessing similar data with population-scale data sources and trusted research environments., Competing Interests: Competing interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: RKO is a member of the National Institute for Health and Care Excellence (NICE) Technology Appraisal Committee, member of the NICE Decision Support Unit (DSU)and associate member of the NICE Technical Support Unit (TSU). She has served as a paid consultant providing unrelated methodological advice to AstraZeneca, Cogentia Healthcare Ltd, Daiichi Sankyo, NICE, the Norwegian Institute of Public Health, Roche and Vifor Pharma. She reports teaching fees from the Association of British Pharmaceutical Industry (ABPI) and the University of Bristol. RH is a member of the Scientific Board of the Smith Institute for Industrial Mathematics and System Engineering. All other authors declare that there are no further conflicts of interest., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Introduction: Exposure to adverse childhood experiences (ACEs) is associated with a range of poor long-term health outcomes, including multimorbidity and chronic pain. Epidemiological evidence underpins much of this relationship; however, psychophysical testing methods, such as quantitative sensory testing (QST), may provide valuable insights into potential mechanisms. Previous studies have shown inconsistent links between ACEs and QST, but the QST profiles of people with multimorbidity have not been reported. We hypothesise that exposure to ACEs is associated with lowered QST thresholds (ie, experience of pain with milder stimuli) and that this association is stronger in adults with multimorbidity and/or chronic pain. The ACE-MAP study is a cross-sectional feasibility study with the primary aim of assessing the feasibility and acceptability of the proposed study procedures. The secondary aim is to generate preliminary data to understand the impact of ACEs on QST thresholds., Methods and Analysis: We plan to recruit 40 participants, with 10 in each of the following groups: (1) chronic pain with multimorbidity; (2) chronic pain without multimorbidity; (3) multimorbidity without chronic pain; and (4) controls. Participants will complete a series of questionnaires (including on ACEs, chronic pain and long-term conditions) and will then take part in QST assessments. The primary study outcomes will include measures of feasibility and acceptability of the proposed study design. The secondary study outcomes will include exploratory analysis on the relationship between ACEs and QST thresholds., Ethics and Dissemination: The study was approved by the Scotland B Research Ethics Committee (reference: 24/SS/0031). Results from the study will be presented at scientific conferences, published in a peer-reviewed journal and shared with patients and members of the public through other media streams., Trial Registration Number: ISRCTN10049430., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Objective: To examine existing literature regarding health literacy levels and their association with multimorbidity and the potential underlying mechanisms behind the said association., Design: Systematic review and meta-analysis., Data Sources: The databases MEDLINE, EMBASE, CINAHL and Science Direct were searched for articles published between 1 January 2000 and 31 October 2023 using a systematic search strategy., Eligibility Criteria: Included were all primary studies conducted in people over 18 years old with data on health literacy levels and the presence of multimorbidity. No language restrictions were used., Data Extraction and Synthesis: Two authors independently extracted data and assessed the bias using the Joanna Briggs Institute critical appraisal tools., Results: We included a total of 39 studies (36 quantitative, two qualitative and one mixed-method), representing 154 337 participants. We found a 32% proportion of limited health literacy among individuals with multimorbidity. Analysis of three articles using the Health Literacy Questionnaire tool (n=31 228) (Pooled OR 2.88 (95% CI 1.92 to 4.31)) and three articles using the Health Literacy Survey Questionnaire-European Union tool (n=35 358) (OR 1.16 (95% CI 1.07 to 1.25)) indicated that people with limited health literacy were likely to have multiple conditions. One of three articles studying underlying mechanisms reported that self-efficacy mediates the association between health literacy and multimorbidity. Additionally, substantial literature identified education and income as the most consistent determinants of health literacy among individuals with multimorbidity. Of the only two articles studying the effectiveness of health literacy-related interventions, both reported an improvement in clinical outcomes after the intervention., Conclusions: Our review demonstrated a consistent association between health literacy and multimorbidity, indicating that people with lower health literacy levels are more likely to have multimorbidity. More evidence is needed regarding the effect of health literacy interventions on multimorbidity., Prospero Registration Number: CRD42022301369., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The prognosis of older adults is strongly influenced by the relation of multifactorial geriatric syndromes (GS) and their health-maintaining counterparts, geriatric resources (GR). The present analysis aimed to identify clusters of comorbidities, GS and GR, and to measure their multidimensional prognostic signature in older patients admitted to different healthcare settings., Design: Pooled secondary analysis of three longitudinal interventional studies with the 3- and 6-month follow-up data collection on mortality and rehospitalisation., Setting: Inpatients in an internal medicine ward (n=495), inpatients in an ageing medicine ward (n=123) and outpatients from a general practice (n=105)., Participants: A total of 734 patients with multimorbidity who aged over 60 years were recruited between August 2016 and July 2020 (mean age 77.8 years, SD 6.2 and 43% female)., Outcome Measures: Comprehensive Geriatric Assessment (CGA), including Cumulative Illness Rating Scale (CIRS), 17 GS and 10 GR, and the CGA-based Multidimensional Prognostic Index (MPI) as a measure of multidimensional prognosis and frailty were assessed. Based on a general linear model and a hierarchical clustering method, clusters of comorbidities, GS and GR were obtained., Results: The study identified five clusters of GR-related GS, namely, psychosocial, iatrogenic, neurovegetative, sensorimotor and fluid dysbalance, along with two clusters related to GR, focusing on independence achievement and requirements- circumstances. Additionally, two clusters were identified pertaining to the CIRS, encompassing sensory-vegetative and heart-kidney morbidity. Patients within the iatrogenic cluster exhibited significantly higher MPI and readmissions during follow-up compared with those outside this cluster (p<0.001). Furthermore, membership in the fluid dysbalance or psychosocial cluster was associated with a significantly increased mortality rate during follow-up (p<0.001)., Conclusions: A feasible combination of GR and GS in clinical routine enables the identification of clusters with clear prognostic relevance, which may improve prognosis through tailored treatment., Trial Registration Numbers: DRKS00010606/DRKS00013791/DRKS00017094 MPI&#95;InGAH , DRKS00012820 MPI&#95;NoGeP and DRKS00015996 VNKN., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objective: To understand barriers and facilitators for strengthening health systems for person-centred care of people with multiple long-term conditions-multimorbidity (MLTC-M) at the primary healthcare (PHC) level in low-income and middle-income countries (LMICs)., Design: A scoping review., Methods: We adopted a systematic scoping review approach to chart literature guided by Arksey and O'Malley's methodological framework. The review focused on studies conducted in LMICs' PHC settings from January 2010 to December 2023. Papers were extracted from the following databases: PubMed, EBSCOhost and Google Scholar. Framework analysis was undertaken to identify barriers and facilitators for strengthening MLTC-M primary care according to the five health system pillars in the Lancet Global Health Commission on High-Quality Health Systems Framework., Results: The literature search yielded 4322 citations, evaluated 202 studies and identified 36 for inclusion. Key barriers within the people pillar included poverty, low health education and low health literacy; within the platform pillar, fragmented services and lack of multimorbid care guidelines were mentioned; within the workforce pillar, lack of required skills and insufficient health workers; and in the tools pillar: a shortage of essential medicines and adverse polypharmacy effects were prominent. A lack of political will and the absence of relevant national health policies were identified under the governance pillar. Facilitators within the people pillar included enhancing self-management support; within the platforms, pillar included integration of services; within the tools pillar, included embracing emerging technologies and information and communication technology services; and governance issues included upscaling interventions to respond to multimorbid care needs through enhanced political commitment and financial support., Conclusions: Potential solutions to strengthening the healthcare system to be more responsive to people with MLTC-M include empowering service users to self-manage, developing multimorbid care guidelines, incorporating community health workers into multimorbid care efforts and advocating for integrated person-centred care services across sectors. The need for policies and procedures in LMICs to meet the person-centred care needs of people with MLTC-M was highlighted., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Clinical guidelines recommend the use of the kidney failure risk equation (KFRE) to guide the referral of individuals with chronic kidney disease (CKD) to secondary kidney care services. People living with CKD frequently experience multiple long-term conditions (multimorbidity) and/or frailty. This may impact patients' or carers' perceptions of kidney failure in the context of other health problems and associated risks and emphasises the need for shared decision-making. This paper presents the research protocol for the exploration of patients' and healthcare professionals' perspectives on kidney failure risk and the use of the KFRE in the MULTIPle lOng-term condItions aNd frailTy study. This study aims to investigate patient and healthcare professionals' perspectives and expectations of the use of KFRE in individuals with CKD and multimorbidity and/or frailty, with a focus on shared decision-making., Methods and Analysis: Analysis of semistructured interviews with adults who have CKD and multimorbidity and/or frailty and focus groups with healthcare professionals (who are involved in caring for patients with CKD). Framework analysis, underpinned by normalisation process theory, will be used to develop codes and explore themes from the interviews and focus groups. Patient and public involvement has been pivotal to the study conceptualisation and will continue to be embedded throughout the study., Ethics and Dissemination: The study protocol has undergone peer review by the NHS Greater Glasgow and Clyde Research and Innovation team and has been granted ethical approval in August 2023 by the NHS Health Research Authority following a favourable opinion from the West of Scotland Research Ethics Committee (REC) 3 (IRAS ID: 325848, REC reference: 23WS/0119, Protocol number GN22RE559).The results of the research will be disseminated through peer-reviewed publications and conferences, as well as to patient and public involvement groups who have been involved in the study and through knowledge exchange events., Competing Interests: Competing interests: PBM reports lecture honoraria from Astrazeneca, Pharmacomsos, Bayer, Astellas, GSK and Boehringer Ingelheim outside the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objective: This study aims to further explore the relevant influencing factors of depression and explore the correlation between multimorbidity coexistence and depression to find the goals and methods of early intervention of depression in the elderly., Design: This study adopts a cross-sectional approach., Setting: The study population of this project came from the China Health and Retirement Longitudinal Study. Depression was grouped according to the 10-item version of Centre for Epidemiological Research Depression Scale. Chronic diseases, height, weight, grip strength, education, marital status, alcohol consumption, exercise and other indicators were included in the analysis., Participants: 2239 adults over 60 years of age were included., Results: The proportion of women in the depression group was higher (p<0.001). The depression group had a lower grip strength than the control group (p<0.05). The sleep duration was shorter in the depression group (p<0.001). There were differences in education, marital status and alcohol consumption in the depression group (p<0.05). The depression group might have more types of coexisting chronic diseases (p<0.001). The depression group was more likely to have hypertension, dyslipidaemia, chronic lung diseases, heart attack, stroke, stomach disease and memory-related disease. Grip strength was connected with the risk of depression in the elderly (0.971 (95% CI 0.959 to 0.984)). Sleep (0.827 (95% CI 0.785 to 0.872) and education level (0.790 (95% CI 0.662 to 0.942) were related to the risk of depression in the elderly. Concomitant chronic diseases could affect the risk of depression in the elderly (1.455 (95% CI 1.243 to 1.703))., Conclusion: The coexistence of multiple chronic diseases and depression is very common in the elderly. The coexistence of multiple chronic diseases is more common in older women and older depressed people. With the increase in the number of chronic diseases, the risk of depression in the elderly is significantly increased., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To investigate the association between multimorbidity during pregnancy and neurodevelopmental delay in offspring using data from a Japanese nationwide birth cohort study., Design: This study was a prospective birth cohort study., Setting: This study population included 104 059 fetal records who participated in The Japan Environment and Children's Study from 2011 to 2014., Participants: Pregnant women whose children had undergone developmental testing were included in this analysis., Primary and Secondary Outcome Measures: Neurodevelopment of offspring was assessed using the Japanese version of the Ages and Stages Questionnaire, third edition, comprising five developmental domains. The number of comorbidities among the pregnant women was categorised as zero, single disease or multimorbidity (two or more diseases). Maternal chronic conditions included in multimorbidity were defined as conditions with high prevalence among women of reproductive age. A multivariate logistic regression analysis was conducted to examine the association between multimorbidity in pregnant women and offspring development., Results: Pregnant women with multimorbidity, single disease and no disease accounted for 3.6%, 30.6% and 65.8%, respectively. The ORs for neurodevelopmental impairment during the follow-up period were similar for infants of mothers with no disease comorbidity and those with a single disease comorbidity. However, the ORs for neurodevelopmental impairment were significantly higher for children born to mothers with multimorbidity compared with those born to healthy mothers., Conclusion: An association was observed between the number of comorbidities in pregnant women and developmental delay in offspring. Multimorbidity in pregnant women may be associated with neurodevelopmental delay in their offspring. Further research is required in this regard in many other regions of the world., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are common in multimorbid patients. This study aims to describe PIMs and PPOs in an open-access outpatient setting and to investigate any association between continuity of care (CoC) and PIMs and PPOs in multimorbid older patients., Design: Cross-sectional study using patient-confirmed outpatient medication plans to describe PIMs and PPOs using the 'Screening Tool of Older Person's Prescription/Screening Tool to Alert to Right Treatment' version 2. Four Poisson regressions modelled the number of PIMs and PPOs using context-adapted versions of the Usual Provider of Care (UPC) and the Modified Modified Continuity Index (MMCI) as measures for CoC., Setting: Southern Germany, outpatient setting., Participants: 321 participants of the LoChro-trial at 12-month follow-up (both arms). The LoChro-trial compared healthcare involving an additional care manager with usual care. Inclusion criteria were age over 64, local residence and scoring over one in the Identification of Older patients at Risk Screening Tool., Primary Outcomes: Numbers of PIMs and PPOs., Results: The mean number of PIMs was 1.5 (SD 1.5), lower than the average number of PPOs at 2.9 (SD 1.7). CoC showed similar results for both indices with a mean of 0.548 (SD 0.279) for MMCI and 0.514 (SD 0.262) for UPC. Both models predicting PPOs indicated more PPOs with higher CoC; statistical significance was only demonstrated for MMCI (MMCI~PPO: Exp(B)=1.42, 95% CI (1.11; 1.81), p=0.004; UPC~PPO: Exp(B)=1.29, 95% CI (0.99; 1.67), p=0.056). No significant association between PIMs and CoC was found (MMCI~PIM: Exp(B)=0.72, 95% CI (0.50; 1.03), p=0.072; UPC~PIM: Exp(B)=0.83, 95% CI (0.57; 1.21), p=0.337)., Conclusion: The results did not show a significant association between higher CoC and lesser PIMs. Remarkably, an association between increased CoC, represented through MMCI, and more PPOs was found. Consultation of different care providers in open-access healthcare systems could possibly ameliorate under-prescribing in multimorbid older patients., Trial Registration: German Clinical Trials Register (DRKS): DRKS00013904., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To classify older adults into clusters based on accumulating long-term conditions (LTC) as trajectories, characterise clusters and quantify their associations with all-cause mortality., Design: We conducted a longitudinal study using the English Longitudinal Study of Ageing over 9 years (n=15 091 aged 50 years and older). Group-based trajectory modelling was used to classify people into clusters based on accumulating LTC over time. Derived clusters were used to quantify the associations between trajectory memberships, sociodemographic characteristics and all-cause mortality by conducting regression models., Results: Five distinct clusters of accumulating LTC trajectories were identified and characterised as: 'no LTC' (18.57%), 'single LTC' (31.21%), 'evolving multimorbidity' (25.82%), 'moderate multimorbidity' (17.12%) and 'high multimorbidity' (7.27%). Increasing age was consistently associated with a larger number of LTCs. Ethnic minorities (adjusted OR=2.04; 95% CI 1.40 to 3.00) were associated with the 'high multimorbidity' cluster. Higher education and paid employment were associated with a lower likelihood of progression over time towards an increased number of LTCs. All the clusters had higher all-cause mortality than the 'no LTC' cluster., Conclusions: The development of multimorbidity in the number of conditions over time follows distinct trajectories. These are determined by non-modifiable (age, ethnicity) and modifiable factors (education and employment). Stratifying risk through clustering will enable practitioners to identify older adults with a higher likelihood of worsening LTC over time to tailor effective interventions to prevent mortality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To compare the patterns of multimorbidity between people with and without rheumatic and musculoskeletal diseases (RMDs) and to describe how these patterns change by age and sex over time, between 2010 and 2019., Participants: 103 426 people with RMDs and 2.9 million comparators registered in 395 Wales general practices (GPs). Each patient with an RMD aged 0-100 years between January 2010 and December 2019 registered in Clinical Practice Research Welsh practices was matched with up to five comparators without an RMD, based on age, gender and GP code., Primary Outcome Measures: The prevalence of 29 Elixhauser-defined comorbidities in people with RMDs and comparators categorised by age, gender and GP practices. Conditional logistic regression models were fitted to calculate differences (OR, 95% CI) in associations with comorbidities between cohorts., Results: The most prevalent comorbidities were cardiovascular risk factors, hypertension and diabetes. Having an RMD diagnosis was associated with a significantly higher odds for many conditions including deficiency anaemia (OR 1.39, 95% CI (1.32 to 1.46)), hypothyroidism (OR 1.34, 95% CI (1.19 to 1.50)), pulmonary circulation disorders (OR 1.39, 95% CI 1.12 to 1.73) diabetes (OR 1.17, 95% CI (1.11 to 1.23)) and fluid and electrolyte disorders (OR 1.27, 95% CI (1.17 to 1.38)). RMDs have a higher proportion of multimorbidity (two or more conditions in addition to the RMD) compared with non-RMD group (81% and 73%, respectively in 2019) and the mean number of comorbidities was higher in women from the age of 25 and 50 in men than in non-RMDs group., Conclusion: People with RMDs are approximately 1.5 times as likely to have multimorbidity as the general population and provide a high-risk group for targeted intervention studies. The individuals with RMDs experience a greater load of coexisting health conditions, which tend to manifest at earlier ages. This phenomenon is particularly pronounced among women. Additionally, there is an under-reporting of comorbidities in individuals with RMDs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Diabetes and depression are among the 10 biggest health burdens globally. They often coexist and exhibit a strong bidirectional relationship. Depression leads to decreased adherence to self-care activities. This impacts glycaemic control and worsens type 2 diabetes mellitus (T2D). Both conditions have a synergistic effect and lead to greater complications, hospitalisations, healthcare expenditure and a worse quality of life. There is no consensus on managing people with comorbid T2D and depression. Bupropion is an efficacious antidepressant with many properties suitable for T2D with depression, including a favourable metabolic profile, persistent weight loss and improvement in sexual dysfunction. We will assess the efficacy and safety of add-on bupropion compared with standard care in people with T2D and mild depression. This study can give valuable insights into managing the multimorbidity of T2D and depression. This can help mitigate the health, social and economic burden of both these diseases., Research Design and Methods: This cross-over randomised controlled trial will recruit people with T2D (for 5 years or more) with mild depression. They will be randomised to add-on bupropion and standard care. After 3 months of treatment, there will be a washout period of 1 month (without add-on bupropion while standard treatment will continue). Following this, the two arms will be swapped. Participants will be assessed for glycosylated haemoglobin, adherence to diabetes self-care activities, lipid profile, urine albumin-to-creatinine ratio, autonomic function, sexual function, quality of life and adverse events., Ethics and Dissemination: The Institutional Ethics Committee at All India Institute of Medical Sciences, Jodhpur has approved this study (AIIMS/IEC/2022/4172, 19 September 2022). We plan to disseminate the research findings via closed group discussions at the site of study, scientific conferences, peer-reviewed published manuscripts and social media., Trial Registration Number: CTRI/2022/10/046411., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Polypharmacy is common among individuals with multimorbidity, often leading to inappropriate medication use and is associated with an increased risk of frailty, hospitalisation and mortality. Structured medication reviews (SMRs) have emerged as a promising method for optimising medication use. However, research examining their efficacy is limited. This review aims to evaluate the impact of SMRs on improving outcomes for adults with multimorbidity and polypharmacy in primary care settings. Additionally, this review seeks to identify prevailing patterns and trends in the mode of delivery of SMRs., Methods and Analysis: A systematic review will be conducted using Ovid MEDLINE, Ovid EMBASE, Web of Science and CINAHL (1997-present). Primary outcomes will include medication-related measures such as dose, frequency and dosage form. Secondary outcomes under investigation will include physical, mental, functional and health service outcomes, as reported. Two independent reviewers will conduct the screening and data extraction, resolving disagreements through discussion. Once eligible studies are identified, the extracted data will be summarised in tabular format. The risk of bias in the articles will be assessed using either the Cochrane Risk of Bias 2 tool or the Newcastle-Ottawa scale, depending on the design of the studies retrieved. Subgroup analysis will be performed using demographic variables and modes of delivery where the data supports. If appropriate, a meta-analysis of the data extracted will be conducted to determine the impact of the SMRs on reported outcomes. If a meta-analysis is not possible due to heterogeneity, a narrative synthesis approach will be adopted., Ethics and Dissemination: This proposed review is exempt from ethical approval as it aims to collate and summarise peer-reviewed, published evidence. This protocol and the subsequent review will be disseminated in peer-reviewed journals, conferences and patient-led lay summaries., Prospero Registration Number: CRD42023454965., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Empowering people living with multimorbidity (multiple chronic conditions) to gain greater confidence in managing their health can enhance their quality of life. Education focused on self-management is a key tool for fostering patient empowerment and is mostly provided on an individual basis. Virtual communities of practice (VCoP) present a unique opportunity for online education in chronic condition self-management within a social context. This research aims to evaluate the effectiveness/cost-effectiveness of individualised, online self-management education compared with VCoP among middle-aged individuals living with multiple chronic conditions., Methods and Analysis: People aged 30-60, living with ≥2 chronic conditions and receiving care in primary care (PC) centres and outpatient hospital-based clinics in Madrid and Canary Islands will enrol in an 18-month parallel-design, blinded (intervention assessment and data analysts), pragmatic (adhering to the intention-to-treat principle), individually randomised trial. The trial will compare two 12-month web-based educational offers of identical content; one delivered individually (control) and the other with online social interaction (VCoP, intervention). Using repeated measures mixed linear models, with the patient as random effect and allocation groups and time per group as fixed effects, we will estimate between-arm differences in the change in Patient Activation Measure from baseline to 12 months (primary endpoint), including measurements at 6-month and 18-month follow-up. Other outcomes will include measures of depression and anxiety, treatment burden, quality of life. In addition to a process evaluation of the VCoP, we will conduct an economic evaluation estimating the relative cost-effectiveness of the VCoP from the perspectives of both the National Health System and the Community., Ethics and Dissemination: The trial was approved by Clinical Research Ethics Committees of Gregorio Marañón University Hospital in Madrid/Nuestra Señora Candelaria University Hospital in Santa Cruz de Tenerife. The results will be disseminated through workshops, policy briefs, peer-reviewed publications and local/international conferences., Trial Registration Number: NCT06046326., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention., Objectives: To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions., Design: We performed a scoping review as defined by the Joanna Briggs Institute., Setting: The focus was on primary care settings., Data Sources: Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024., Eligibility Criteria: We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded., Extraction and Analysis: We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions., Results: In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention., Conclusions: Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding., Competing Interests: Competing interests: DA reports research funding from Abbvie, Almirall, Celgene, Eli Lilly, Novartis, UCB and the Leo Foundation outside the submitted work. The other authors have no conflicts of interest to disclose., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: There are no data regarding the prevalence of comorbidity (ie, additional conditions in reference to an index disease) and multimorbidity (ie, co-occurrence of multiple diseases in which no one holds priority) in patients with liver cirrhosis. We sought to determine the rate and differences between comorbidity and multimorbidity depending on the aetiology of cirrhosis., Design: This is a subanalysis of the San MAtteo Complexity (SMAC) study. We have analysed demographic, clinical characteristics and rate of comorbidity/multimorbidity of patients with liver cirrhosis depending on the aetiology-alcoholic, infectious and non-alcoholic fatty liver disease (NAFLD). A multivariable analysis for factors associated with multimorbidity was fitted., Setting: Single-centre, cross-sectional study conducted in a tertiary referral, academic, internal medicine ward in northern Italy (November 2017-November 2019)., Participants: Data from 1433 patients previously enrolled in the SMAC study were assessed; only those with liver cirrhosis were eventually included., Results: Of the 1433 patients, 172 (median age 79 years, IQR 67-84; 83 females) had liver cirrhosis. Patients with cirrhosis displayed higher median Cumulative Illness Rating Scale (CIRS) comorbidity (4, IQR 3-5; p=0.01) and severity (1.85, IQR 16.-2.0; p<0.001) indexes and lower educational level (103, 59.9%; p=0.003). Patients with alcohol cirrhosis were significantly younger (median 65 years, IQR 56-79) than patients with cirrhosis of other aetiologies (p<0.001) and more commonly males (25, 75.8%). Comorbidity was more prevalent in patients with alcohol cirrhosis (13, 39.4%) and multimorbidity was more prevalent in viral (64, 81.0%) and NAFLD (52, 86.7%) cirrhosis (p=0.015). In a multivariable model for factors associated with multimorbidity, a CIRS comorbidity index >3 (OR 2.81, 95% CI 1.14 to 6.93, p=0.024) and admission related to cirrhosis (OR 0.19, 95% CI 0.07 to 0.54, p=0.002) were the only significant associations., Conclusions: Comorbidity is more common in alcohol cirrhosis compared with other aetiologies in a hospital, internal medicine setting., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To understand the physical activity and mental health of individuals living with long-term conditions during the COVID-19 pandemic., Design: A sequential explanatory mixed-methods study with two phases: phase 1: quantitative survey and phase 2: qualitative follow-up interviews., Setting: For the quantitative phase, an online survey was launched in March 2021, using Microsoft Forms. For the qualitative phase, in-depth semistructured interviews were conducted via online., Participants: 368 adults over 18 years old living in the UK with at least one long-term condition completed the survey. Interviews were conducted in a subsample of participants from the previous quantitative phase, with 26 people. Data were analysed using thematic analysis., Results: Responses from the survey showed that people with one long-term condition were significantly more physically active and spent less time sitting, than those with two or more conditions, presenting with significantly higher well-being (p<0.0001), and lower levels of anxiety (p<0.01), and depression (p<0.0001). Interviews found that people developed a range of strategies to cope with the impact of changeability and the consequences of their long-term condition on their physical activity., Conclusions: The number of long-term conditions influenced physical activity and how people coped with their condition during COVID-19. Findings will inform policy developments in preparation for future pandemics to support and remain people to remain physically active and mental health., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To undertake further psychometric testing of the Multimorbidity Treatment Burden Questionnaire (MTBQ) and examine whether reversing the scale reduced floor effects., Design: Survey., Setting: UK primary care., Participants: Adults (≥18 years) with three or more long-term conditions randomly selected from four general practices and invited by post., Measures: Baseline survey: sociodemographics, MTBQ (original or version with scale reversed), Treatment Burden Questionnaire (TBQ), four questions (from QQ-10) on ease of completing the questionnaires. Follow-up survey (1-4 weeks after baseline): MTBQ, TBQ and QQ-10. Anonymous data collected from electronic GP records: consultations (preceding 12 months) and long-term conditions. The proportion of missing data and distribution of responses were examined for the original and reversed versions of the MTBQ and the TBQ. Intraclass correlation coefficient (ICC) and Spearman's rank correlation (R s ) assessed test-retest reliability and construct validity, respectively. Ease of completing the MTBQ and TBQ was compared. Interpretability was assessed by grouping global MTBQ scores into 0 and tertiles (>0)., Results: 244 adults completed the baseline survey (consent rate 31%, mean age 70 years) and 225 completed the follow-up survey. Reversing the scale did not reduce floor effects or data skewness. The global MTBQ scores had good test-retest reliability (ICC for agreement at baseline and follow-up 0.765, 95% CI 0.702 to 0.816). Global MTBQ score was correlated with global TBQ score (R s 0.77, p<0.001), weakly correlated with number of consultations (R s 0.17, p=0.010), and number of different general practitioners consulted (R s 0.23, p<0.001), but not correlated with number of long-term conditions (R s -0.063, p=0.330). Most participants agreed that both the MTBQ and TBQ were easy to complete and included aspects they were concerned about., Conclusion: This study demonstrates test-retest reliability and ease of completion of the MTBQ and builds on a previous study demonstrating good content validity, construct validity and internal consistency reliability of the questionnaire., Competing Interests: Competing interests: PD and CS developed and validated the MTBQ. CS is an NIHR Senior Investigator., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The prescription-based Rx-risk index has previously been developed to measure multimorbidity. We aimed to adapt and evaluate the validity of the Rx-risk index in prediction of mortality among persons with type 2 diabetes., Design: Registry-based study., Setting: Adults with type 2 diabetes in Norway identified within the 'Outcomes and Multimorbidity In Type 2 diabetes' cohort, with linkage to prescriptions from the Norwegian Prescription Database and mortality from the Population Registry., Participants: We defined a calibration sample of 42 290 adults diagnosed with type 2 diabetes 1950-2013, and a temporal validation sample of 7085 adults diagnosed 2014-2016 to evaluate the index validity over time PRIMARY OUTCOME MEASURE: All-cause mortality METHODS: For the calibration sample, dispensed drug prescriptions in 2013 were used to define 44 morbidity categories. Weights were estimated using regression coefficients from a Cox regression model with 5 year mortality as the outcome and all morbidity categories, age and sex included as covariates. The Rx-risk index was computed as a weighted sum of morbidities. The validity of the index was evaluated using C-statistic and calibration plots., Results: In the calibration sample, mean (SD) age at start of follow-up and duration of diabetes was 63.8 (12.4) and 10.1 (7.0) years, respectively. The overall C-statistic was 0.82 and varied from 0.74 to 0.85 when stratifying on age groups, sex, level of education and country of origin. In the validation sample, mean (SD) age and duration of diabetes was 59.7 (13.0) and 2.0 (0.8) years, respectively. Despite younger age, shorter duration of diabetes and later time period, the C-index was high both in the total sample (0.84) and separately for men (0.83) and women (0.84)., Conclusions: The Rx-risk index showed good discrimination and calibration in predicting mortality and thus presents a valid tool to assess multimorbidity among persons with type 2 diabetes., Competing Interests: Competing interests: JI is the head of the Core Facility for Biostatistics and Data Analysis (BIOS) at the University of Bergen which has performed contracted research for Sanofi Aventis and Pfizer on antiseizure medications, not related to this work. ESB is a previous employee of Novo Nordisk (2011–2016) and has offered medical consulting and lectures to Novo Nordisk, Sanofi Aventis and MundiPharma. All other authors declare no conflicts of interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study aimed to identify long-term distinct trajectories of multimorbidity with ageing from 50 to 85 years among Chinese older adults and examine the relationship between exposure to early-life adversity (ELA; including specific types of adversity and accumulation of different adversities) and these long-term multimorbidity trajectories., Design: The group-based trajectory models identified long-term multimorbidity trajectories. Multinomial logistic regression models were used to examine the relationship between ELA and the identified multimorbidity trajectories., Setting: This study used data from the China Health and Retirement Longitudinal Study (CHARLS, 2011-2018) and the 2014 Life History Survey., Participants: We used data from 9112 respondents (aged 60 and above) of the 2018 wave of CHARLS., Outcome Measures: Each respondent's history of chronic conditions and experiences of ELA were collected from the 2011-2018 waves of CHARLS and the 2014 Life History Survey., Results: Four heterogeneous long-term trajectories of multimorbidity development were identified: 'maintaining-low' (19.1%), 'low onset-rapidly increasing' (23.3%), 'middle onset-moderately increasing' (41.5%) and 'chronically-high' (16.2%). Our findings indicated that the heterogeneity can be explained by ELA experiences. Across various types of different ELA experiences, exposure to food insufficiency (relative risk ratios from 1.372 (95% CI 1.190 to 1.582) to 1.780 (95% CI 1.472 to 2.152)) and parental quarrel/divorce (relative risk ratios from 1.181 (95% CI 1.000 to 1.394) to 1.262 (95% CI 1.038 to 1.536)) had the most prominent associations with health deterioration. The accumulation of more different ELA experiences was associated with a higher relative risk of developing more severe multimorbidity trajectories (relative risk ratio for five to seven ELAs and chronically high trajectory: 7.555, 95% CI 4.993 to 11.431)., Conclusions: There are heterogeneous long-term trajectories of multimorbidity in Chinese older adults, and the risk of multimorbidity associated with ELA accumulates over the lifespan. Our findings highlight the role of a supportive early-life family environment in promoting health development across the lifespan, advocating for the integration of life-course approaches to implementing health disparity interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Multimorbidity, the coexistence of two or more chronic conditions in the same individual, is a major public health problem in low-income and middle-income countries (LMICs). The use of single-disease guidelines contributes to polypharmacy, fragmented care and increased treatment burden. Health systems in LMICs are very different from those in high-income countries, and adapting interventions from one to the other may not be feasible. This review aims to systematically present the current evidence for interventions for multimorbidity in the LMIC setting., Methods and Analysis: In this mixed-methods systematic review, we will include all studies of interventions for the care of adults (>18 years of age) with multimorbidity (defined as the presence of two or more chronic illnesses in an individual) in any healthcare organisation (primary, secondary or tertiary care) in an LMIC (as defined by the World Bank), published between 2000 and March 2023. All primary study designs will be included. Studies reported in languages other than English and those describing interventions classified as 'financial' or 'governance arrangement' according to the Cochrane Effective Practice and Organisation of Care classification will be excluded. MEDLINE, PubMed, Cochrane Library, TRIP, SCOPUS and the 3ie databases will be searched. The titles will be screened by one author, and two authors will independently screen all included abstracts and full texts. A third author will resolve conflicts at every stage. Studies will be reviewed for quality of evidence using appropriate tools. Epidemiological, intervention and outcome data will be extracted and summarised. Outcomes of interest for LMICs defined by the Global Alliance for Chronic Diseases research group will be analysed. Subgroup analysis according to study types and study settings will be done., Ethics and Dissemination: No ethics approval is required for this systematic review. Results will be disseminated through publication in an open-access journal and presentation at conferences., Prospero Registration Number: CRD42023391897., Competing Interests: Competing interests: TG has received a fee-offset PhD scholarship from the University of Melbourne (application number 811257). The other authors have no competing interests to declare., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Ethnic minorities (also called racialised groups) are more likely to experience severe mental illness (SMI). People with SMI are more likely to experience multimorbidity (MM), making psychosis among racialised groups more likely to lead to MM, poor outcomes, disability and premature mortality., Methods and Analysis: This National Institute for Health and Care Research-funded study (151887) seeks to use innovative participatory methods including photovoice and biographical narrative interviews in urban and rural areas of England to assemble experience data. These data will be subjected to polytextual thematic analysis, and alongside pictures and captions, will inform an experienced-based co-design of interventions, the implementation of which will be evaluated. There will be an economic analysis and a process evaluation of the implementation., Ethics and Dissemination: This programme of work has received ethical (IRAS 322421; Newcastle North Tyneside Research Ethics Committee 23/NE/0143) and sponsor approval. The findings will be disseminated in galleries showing the creative work, as lay and academic summaries and infographics; as practice briefings for practitioners, commissioners and policy makers; peer-reviewed publications., Trial Registration Number: https://www.researchregistry.com/browse-the-registry%23home/registrationdetails/649c08111c037d0027b17d17/., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objective: Map multimorbidity-weighted index (MWI) conditions to International Classification of Diseases, 10th Revision (ICD-10), expand the conditions and codes to develop a new ICD-10-coded MWI (MWI-ICD10) and updated MWI-ICD9, and assess their consistency., Design: Population-based retrospective cohort., Setting: Large medical centre between 2013 and 2017., Participants: Adults ≥18 years old with encounters in each of 4 years (2013, 2014, 2016, 2017)., Main Outcome Measures: MWI conditions mapped to ICD-10 codes, and additional conditions and codes added to produce a new MWI-ICD10 and updated MWI-ICD9. We compared the prevalence of ICD-coded MWI conditions within the ICD-9 era (2013-2014), within the ICD-10 era (2016-2017) and across the ICD-9-ICD-10 transition in 2015 (washout period) among adults present in both sets of comparison years. We computed the prevalence and change in prevalence of conditions when using MWI-ICD10 versus MWI-ICD9., Results: 88 175 adults met inclusion criteria. Participants were 60.8% female, 50.5% white, with mean age 54.7±17.3 years and baseline MWI-ICD9 4.47±6.02 (range 0-64.33). Of 94 conditions, 65 had <1% difference across the ICD-9-ICD-10 transition and similar minimal changes within ICD coding eras., Conclusions: MWI-ICD10 captured the prevalence of chronic conditions nearly identically to that of the validated MWI-ICD9, along with notable but explicable changes across the ICD-10 transition. This new comprehensive person-centred index enables quantification of cumulative disease burden and physical functioning in adults as a clinically meaningful measure of multimorbidity in electronic health record and claims data., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Patients with complex multimorbidity face a high treatment burden and frequently have low quality of life. General practice is the key organisational setting in terms of offering people with complex multimorbidity integrated, longitudinal, patient-centred care. This protocol describes a pragmatic cluster randomised controlled trial to evaluate the effectiveness of an adaptive, multifaceted intervention in general practice for patients with complex multimorbidity., Methods and Analysis: In this study, 250 recruited general practices will be randomly assigned 1:1 to either the intervention or control group. The eligible population are adult patients with two or more chronic conditions, at least one contact with secondary care within the last year, taking at least five repeat prescription drugs, living independently, who experience significant problems with their life and health due to their multimorbidity. During 2023 and 2024, intervention practices are financially incentivised to provide an extended consultation based on a patient-centred framework to eligible patients. Control practices continue care as usual. The primary outcome is need-based quality of life. Outcomes will be evaluated using linear and logistic regression models, with clustering considered. The analysis will be performed as intention to treat. In addition, a process evaluation will be carried out and reported elsewhere., Ethics and Dissemination: The trial will be conducted in compliance with the protocol, the Helsinki Declaration in its most recent form and good clinical practice recommendations, as well as the regulation for informed consent. The study was submitted to the Danish Capital Region Ethical Committee (ref: H-22041229). As defined by Section 2 of the Danish Act on Research Ethics in Research Projects, this project does not constitute a health research project but is considered a quality improvement project that does not require formal ethical approval. All results from the study (whether positive, negative or inconclusive) will be published in peer-reviewed journals., Trial Registration Number: NCT05676541., Competing Interests: Competing interests: FBW declares having had received funding for research from the Novo Nordisk Foundation and the Velux Foundation. SR declares being a member of the steering committee for the Steno Diabetes Center in Region Zealand on behalf of the institute, without receiving any financial compensation. All other authors declare that they do not have any conflicts of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Coexisting multiple health conditions is common among older people, a population that is increasing globally. The potential for polypharmacy, adverse events, drug interactions and development of additional health conditions complicates prescribing decisions for these patients. Artificial intelligence (AI)-generated decision-making tools may help guide clinical decisions in the context of multiple health conditions, by determining which of the multiple medication options is best. This study aims to explore the perceptions of healthcare professionals (HCPs) and patients on the use of AI in the management of multiple health conditions., Methods and Analysis: A qualitative study will be conducted using semistructured interviews. Adults (≥18 years) with multiple health conditions living in the West Midlands of England and HCPs with experience in caring for patients with multiple health conditions will be eligible and purposively sampled. Patients will be identified from Clinical Practice Research Datalink (CPRD) Aurum; CPRD will contact general practitioners who will in turn, send a letter to patients inviting them to take part. Eligible HCPs will be recruited through British HCP bodies and known contacts. Up to 30 patients and 30 HCPs will be recruited, until data saturation is achieved. Interviews will be in-person or virtual, audio recorded and transcribed verbatim. The topic guide is designed to explore participants' attitudes towards AI-informed clinical decision-making to augment clinician-directed decision-making, the perceived advantages and disadvantages of both methods and attitudes towards risk management. Case vignettes comprising a common decision pathway for patients with multiple health conditions will be presented during each interview to invite participants' opinions on how their experiences compare. Data will be analysed thematically using the Framework Method., Ethics and Dissemination: This study has been approved by the National Health Service Research Ethics Committee (Reference: 22/SC/0210). Written informed consent or verbal consent will be obtained prior to each interview. The findings from this study will be disseminated through peer-reviewed publications, conferences and lay summaries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Key to improving outcomes for patients with multimorbidity is increasing mobility through prescription of a physical activity programme, but this can be difficult to achieve in acute hospital settings. One approach that would assist physiotherapists to increase levels of physical activity is delegation of rehabilitation to allied health assistants. We aim to conduct a randomised controlled trial to determine the feasibility of an allied health assistant providing daily inpatient mobility rehabilitation for patients with multimorbidity., Methods and Analysis: Using a parallel group randomised controlled design, participants will be allocated to allied health assistant mobility rehabilitation or physiotherapist mobility rehabilitation. Adult inpatients (n=60) in an acute hospital with a diagnosis of multimorbidity who walked independently preadmission will be included. The experimental group will receive routine mobility rehabilitation, including daily mobilisation, from an allied health assistant under the supervision of a physiotherapist. The comparison group will receive routine rehabilitation from a physiotherapist. Feasibility will be determined using the following areas of focus in Bowen's feasibility framework: Acceptability (patient satisfaction); demand (proportion of patients who participate); implementation (time allied health assistant/physiotherapist spends with participant, occasions of service); and practicality (cost, adverse events). Staff involved in the implementation of allied health assistant rehabilitation will be interviewed to explore their perspectives on feasibility. Secondary outcomes include: Physical activity (daily time spent walking); daily mobilisation (Y/N); discharge destination; hospital readmission; falls; functional activity (Modified Iowa Level of Assistance Scale); and length of stay. Descriptive statistics will be used to describe feasibility. Secondary outcomes will be compared between groups using Poisson or negative binomial regression, Cox proportional hazards regression, survival analysis, linear regression or logistic regression., Ethics and Dissemination: Ethics approval was obtained from Peninsula Health (HREC/97 431/PH-2023). Findings will be disseminated in peer-reviewed journals and conference presentations., Trial Registration Number: Australian and New Zealand Clinical Trial Registry ACTRN12623000584639p., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: As life expectancy increases, older people are living longer with multimorbidity (MM, co-occurrence of ≥2 chronic health conditions) and complex multimorbidity (CMM, ≥3 chronic conditions affecting ≥3 different body systems). We assessed the impacts of MM and CMM on healthcare service use in Australia, as little was known about this., Design: Population-based cross-sectional data linkage study., Setting: New South Wales, Australia., Participants: 248 496 people aged ≥45 years who completed the Sax Institute's 45 and Up Study baseline questionnaire., Primary Outcome: High average annual healthcare service use (≥2 hospital admissions, ≥11 general practice visits and ≥2 emergency department (ED) visits) during the 3-year baseline period (year before, year of and year after recruitment)., Methods: Baseline questionnaire data were linked with hospital, Medicare claims and ED datasets. Poisson regression models were used to estimate adjusted and unadjusted prevalence ratios for high service use with 95% CIs. Using a count of chronic conditions (disease count) as an alternative morbidity metric was requested during peer review., Results: Prevalence of MM and CMM was 43.8% and 15.5%, respectively, and prevalence increased with age. Across three healthcare settings, MM was associated with a 2.02-fold to 2.26-fold, and CMM was associated with a 1.83-fold to 2.08-fold, increased risk of high service use. The association was higher in the youngest group (45-59 years) versus the oldest group (≥75 years), which was confirmed when disease count was used as the morbidity metric in sensitivity analysis.When comparing impact using three categories with no overlap (no MM/CMM, MM with no CMM, and CMM), CMM had greater impact than MM across all settings., Conclusion: Increased healthcare service use among older adults with MM and CMM impacts on the demand for primary care and hospital services. Which of MM or CMM has greater impact on risk of high healthcare service use depends on the analytic method used. Ageing populations living longer with increasing burdens of MM and CMM will require increased Medicare funding and provision of integrated care across the healthcare system to meet their complex needs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Older surgical patients are more likely to be living with frailty and multimorbidity and experience postoperative complications. The management of these conditions in the perioperative pathway is evolving. In order to support objective decision-making for patients, services and national guidance, accurate, contemporary data are needed to describe the impact and associations between frailty, multimorbidity and healthcare processes with patient and service-level outcomes., Methods and Analysis: The study is comprised of an observational cohort study of approximately 7500 patients; an organisational survey of perioperative services and a clinician survey of the unplanned, medical workload generated from older surgical patients. The cohort will consist of patients who are 60 years and older, undergoing a surgical procedure during a 5-day recruitment period in participating UK hospitals. Participants will be assessed for baseline frailty and multimorbidity; postoperative morbidity including delirium; and quality of life. Data linkage will provide additional details about individuals, their admission and mortality.The study's primary outcome is length of stay, other outcome measures include incidence of postoperative morbidity and delirium; readmission, mortality and quality of life. The cohort's incidence of frailty, multimorbidity and delirium will be estimated using 95% CIs. Their relationships with outcome measures will be examined using unadjusted and adjusted multilevel regression analyses. Choice of covariates in the adjusted models will be prespecified, based on directed acyclic graphs.A parallel study is planned to take place in Australia in 2022., Ethics and Dissemination: The study has received approval from the Scotland A Research Ethics Committee and Wales Research Ethics Committee 7.This work hopes to influence the development of services and guidelines. We will publish our findings in peer-reviewed journals and provide summary documents to our participants, sites, healthcare policy-makers and the public., Trial Registration Number: ISRCTN67043129., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Managing older adults with multimorbidity may be challenging due to the conflicting benefits and harms of multiple treatments. Thus, it is important to identify patients' health outcome priorities to align treatment goals with their health preferences. This study aimed to use the Outcome Prioritisation Tool (OPT) to describe the health outcome priorities of older adults with multimorbidity and determine the factors associated with these priorities. Additionally, it aimed to assess the ease of completing the OPT in Singapore's primary care population., Design: Cross-sectional study conducted from January to March 2022., Setting: A public primary care centre in Singapore., Participants: 65 years and older with multimorbidity., Outcome Measures: Primary outcome measure was the most important health outcome priorities on the OPT. Secondary outcome measures were factors affecting these priorities and ease of completing the OPT., Results: We enrolled 180 participants (mean age: 73.2±6.1 years). Slightly more than half (54.4%) prioritised 'staying alive', while the remainder (45.6%) prioritised 'maintaining independence' (25.6%), 'relieving pain' (10.6%) and 'relieving other symptoms' (9.4%). Participants with six or more chronic conditions were three times (OR 3.03 (95% CI1.09 to 8.42)) more likely to prioritise 'staying alive' compared with participants with three conditions. Most participants (69.4%) agreed that the OPT was easy to complete, and the mean time taken to complete the OPT was 3.8±1.6 minutes., Conclusion: 'Staying alive' was the most important health outcome priority, especially for older adults with six or more chronic conditions. The OPT was easily completed among older adults with multimorbidity in primary care. Further qualitative studies can be conducted to understand the factors influencing patients' priorities and explore the relevance of the OPT in guiding treatment decisions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Multimorbidity is defined as the presence of two or more chronic diseases. Co-occurring diseases can have synergistic negative effects, and are associated with significant impacts on individual health outcomes and healthcare systems. However, the specific effects of diseases in combination will vary between different diseases. Identifying which diseases are most likely to co-occur in multimorbidity is an important step towards population health assessment and development of policies to prevent and manage multimorbidity more effectively and efficiently. The goal of this project is to conduct a systematic review and meta-analysis of studies of disease clustering in multimorbidity, in order to identify multimorbid disease clusters and test their stability., Methods and Analysis: We will review data from studies of multimorbidity that have used data clustering methodologies to reveal patterns of disease co-occurrence. We propose a network-based meta-analytic approach to perform meta-clustering on a select list of chronic diseases that are identified as priorities for multimorbidity research. We will assess the stability of obtained disease clusters across the research literature to date, in order to evaluate the strength of evidence for specific disease patterns in multimorbidity., Ethics and Dissemination: This study does not require ethics approval as the work is based on published research studies. The study findings will be published in a peer-reviewed journal and disseminated through conference presentations and meetings with knowledge users in health systems and public health spheres., Prospero Registration Number: CRD42023411249., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: People living with and dying from multimorbidity are increasing in number, and ensuring quality care for this population is one of the major challenges facing healthcare providers. People with multimorbidity often have a high burden of palliative and end-of-life care needs, though they do not always access specialist palliative care services. A key reason for this is that they are often not identified as being in the last stages of their life by current healthcare providers and systems.This scoping review aims to identify and present the available evidence on how people with multimorbidity are currently included in research, policy and clinical practice., Methods and Analysis: Scoping review methodology, based on Arksey and O'Malley's framework, will be undertaken and presented using the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Search terms have been generated using the key themes of 'multimorbidity', 'end of life' and 'palliative care'. Peer-reviewed research will be obtained through systematic searching of Medline, EMBASE, CINAHL, Scopus and PsycINFO. Grey literature will be searched in a systematic manner. Literature containing a definition for adults with multimorbidity in a terminal phase of their illness experience will be included. After screening studies for eligibility, included studies will be described in terms of setting and characteristics as well as using inductive content analysis to highlight the commonalities in definitions., Ethics and Dissemination: Ethical approval is not required for this scoping review. The findings of the scoping review will be used internally as part of SPB's PhD thesis at the University of St Andrews through the Multimorbidity Doctoral Training Programme for Health Professionals, which is supported by the Wellcome Trust (223499/Z/21/Z) and published in an open access, peer-reviewed journal for wider dissemination., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: The epidemiological and demographic transitions are leading to a rising burden of multimorbidity (co-occurrence of two or more chronic conditions) worldwide. Evidence on the burden, determinants, consequences and care of multimorbidity in rural and urbanising India is limited, partly due to a lack of longitudinal and objectively measured data on chronic health conditions. We will conduct a mixed-methods study nested in the prospective Andhra Pradesh Children and Parents' Study (APCAPS) cohort to develop a data resource for understanding the epidemiology of multimorbidity in rural and urbanising India and developing interventions to improve the prevention and care of multimorbidity., Methods and Analysis: We aim to recruit 2100 APCAPS cohort members aged 45+ who have clinical and lifestyle data collected during a previous cohort follow-up (2010-2012). We will screen for locally prevalent non-communicable, infectious and mental health conditions, alongside cognitive impairments, disabilities and frailty, using a combination of self-reported clinical diagnosis, symptom-based questionnaires, physical examinations and biochemical assays. We will conduct in-depth interviews with people with varying multimorbidity clusters, their informal carers and local healthcare providers. Deidentified data will be made available to external researchers., Ethics and Dissemination: The study has received approval from the ethics committees of the National Institute of Nutrition and Indian Institute of Public Health Hyderabad, India and the London School of Hygiene and Tropical Medicine, UK. Meta-data and data collection instruments will be published on the APCAPS website alongside details of existing APCAPS data and the data access process (www.lshtm.ac.uk/research/centres-projects-groups/apcaps)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Health information systems represent an opportunity to improve the care provided to people with multimorbidity. There is a pressing need to assess their impact on clinical outcomes to validate this intervention. Our study will determine whether using a digital platform (Multimorbidity Management Health Information System, METHIS) to manage multimorbidity improves health-related quality of life (HR-QoL)., Methods and Analysis: A superiority, cluster randomised trial will be conducted at primary healthcare practices (1:1 allocation ratio). All public practices in the Lisbon and Tagus Valley (LVT) Region, Portugal, not involved in a previous pilot trial, will be eligible. At the participant level, eligible patients will be people with complex multimorbidity, aged 50 years or older, with access to an internet connection and a communication technology device. Participants who cannot sign/read/write and who do not have access to an email account will not be included in the study. The intervention combines a training programme and a customised information system (METHIS). Both are designed to help clinicians adopt a goal-oriented care model approach and to encourage patients and carers to play a more active role in autonomous healthcare. The primary outcome is HR-QoL, measured at 12 months with the physical component scale of the 12-item Short Form questionnaire (SF-12). Secondary outcomes will also be measured at 12 months and include mental health (mental component Scale SF-12, Hospital Anxiety and Depression Scale). We will also assess serious adverse events during the trial, including hospitalisation and emergency services. Finally, at 18 months, we will ask the general practitioners for any potentially missed diagnoses., Ethics and Dissemination: The Research and Ethics Committee (LVT Region) approved the trial protocol. Clinicians and patients will sign an informed consent. A data management officer will handle all data, and the publication of several scientific papers and presentations at relevant conferences/workshops is envisaged., Trial Registration Number: NCT05593835., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The aim of this study is to establish a self-simple-to-use nomogram to predict the risk of multimorbidity among middle-aged and older adults., Design: A retrospective cohort study., Participants: We used data from the Chinese Longitudinal Healthy Longevity Survey, including 7735 samples., Main Outcome Measures: Samples' demographic characteristics, modifiable lifestyles and depression were collected. Cox proportional hazard models and nomogram model were used to estimate the risk factors of multimorbidity., Results: A total of 3576 (46.2%) participants have multimorbidity. The result showed that age, female (HR 0.80, 95% CI 0.72 to 0.89), chronic disease (HR 2.59, 95% CI 2.38 to 2.82), sleep time (HR 0.78, 95% CI 0.72 to 0.85), regular physical activity (HR 0.88, 95% CI 0.81 to 0.95), drinking (HR 1.27 95% CI 1.16 to 1.39), smoking (HR 1.40, 95% CI 1.26 to 1.53), body mass index (HR 1.04, 95% CI 1.03 to 1.05) and depression (HR 1.02, 95% CI 1.01 to 1.03) were associated with multimorbidity. The C-index of nomogram models for derivation and validation sets were 0.70 (95% CI 0.69 to 0.71, p=0.006) and 0.71 (95% CI 0.70 to 0.73, p=0.008), respectively., Conclusions: We have crafted a user-friendly nomogram model for predicting multimorbidity risk among middle-aged and older adults. This model integrates readily available and routinely assessed risk factors, enabling the early identification of high-risk individuals and offering tailored preventive and intervention strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)