Observational Study Medicine ®

Multimorbidity, healthcare utilization, and quality

of life for older patients undergoing surgery
A prospective study
Chayanan Thanakiattiwibun, MSca,b, Arunotai Siriussawakul, MDa,b,* , Tithita Virotjarumart, MDc,
Satanun Maneeon, MSc (Pharm)d,e, Narisa Tantai, MSc (Pharm)d,e, Varalak Srinonprasert, MDa,e,f,
Onuma Chaiwat, MDa,b, Patcharee Sriswasdi, MDb

Abstract
Multimorbidity (≥2 chronic illnesses) is a worldwide healthcare challenge. Patients with multimorbidity have a reduced quality of life
and higher mortality than healthy patients and use healthcare resources more intensively. This study investigated the prevalence of
multimorbidity; examined the effects of multimorbidity on healthcare utilization; healthcare costs of multimorbidity; and compared
the associations between the health-related quality of life (HRQoL) of older patients undergoing surgery and multimorbidity, the
Charlson Comorbidity Index (CCI), the Simple Frailty Questionnaire (FRAIL), and the American Society of Anesthesiologists (ASA)
physical status classifications. This prospective cohort study enrolled 360 patients aged > 65 years scheduled for surgery at a
university hospital. Data were collected on their demographics, preoperative medical profiles, healthcare costs, and healthcare
utilization (the quantification or description of the use of services, such as the number of preoperative visits, multiple-department
consultations, surgery waiting time, and hospital length of stay). Preoperative-assessment data were collected via the CCI, FRAIL
questionnaire, and ASA classification. HRQoL was derived using the EQ-5D-5L questionnaire. The 360 patients had a mean age
of 73.9 ± 6.6 years, and 37.8% were men. Multimorbidity was found in 285 (79%) patients. The presence of multimorbidity had
a significant effect on healthcare utilization (≥2 preoperative visits and consultations with ≥2 departments). However, there was
no significant difference in healthcare costs between patients with and without multimorbidity. At the 3-month postoperative,
patients without multimorbidity had significantly higher scores for HRQoL compared to those with multimorbidity (HRQoL = 1.00
vs 0.96; P < .007). While, patients with ASA Class > 2 had a significantly lower median HRQoL than patients with ASA Class ≤2
at postoperative day 5 (HRQoL = 0.76; P = .018), 1-month (HRQoL = 0.90; P = .001), and 3-months (HRQoL = 0.96; P < .001)
postoperatively. Multimorbidity was associated with a significant increase in the healthcare utilization of the number of preoperative
visits and a greater need for multiple-department consultations. In addition, multimorbidity resulted in a reduced HRQoL during
hospital admission and 3-months postoperatively. In particular, the ASA classification > 2 apparently reduced postoperative
HRQoL at day 5, 1-month, and 3-months lower than the ASA classification ≤2.
Abbreviations: ASA = American Society of Anesthesiologists’ physical status classifications, CCI = Charlson comorbidity
index, CSMBS = Civil Servant Medical Benefit Scheme, FRAIL = the Simple Frailty Questionnaire, HRQoL = health-related quality
of life, UCS = Universal Coverage Scheme.
Keywords: healthcare cost, healthcare utilization, health-related quality of life, multimorbidity, older, surgical patient

1. Introduction
Globally, the aging population is increasing rapidly. According
to World Population Prospects 2019, by 2050, 16% of the world
population will be over age 65, which is almost twice the level
in 2019.[1] An aging society will soon become one of the most
significant social transformations, with implications for multi-
ple aspects, including economic and healthcare systems.[2] Given
the growing number of older individuals, the expected increase
in patients with chronic diseases, and the increased availability

This research project was supported by the Faculty of Medicine Siriraj Hospital,
Mahidol University (grant number [IO] R016131036). The funder had no role in the
study design, data collection and analysis, decision to publish, or preparation of
the manuscript
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are
available from the corresponding author on reasonable request.
Supplemental Digital Content is available for this article.
a
Integrated Perioperative Geriatric Excellent Research Center, Faculty of Medicine
Siriraj Hospital, Mahidol University, Bangkok, Thailand, b Department of Anesthesiology,
Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand,
c
Department of Anesthesiology, Phaholpolpayuhasena Hospital, Kanchanaburi,
Thailand, d Department of Pharmacy, Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok, Thailand, e Siriraj Health Policy Unit, Faculty of Medicine Siriraj
Hospital, Mahidol University, Bangkok, Thailand, f Division of Geriatrics, Department of
Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
*Correspondence: Arunotai Siriussawakul, Department of Anesthesiology, Faculty
of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand (e-mail:
arunotai.sir@mahidol.ac.th).
Copyright © 2023 the Author (s). Published by Wolters Kluwer Health, Inc.
This is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is
permissible to download, share, remix, transform, and buildup the work provided
it is properly cited. The work cannot be used commercially without permission
from the journal.
How to cite this article: Thanakiattiwibun C, Siriussawakul A, Virotjarumart T,
Maneeon S, Tantai N, Srinonprasert V, Chaiwat O, Sriswasdi P. Multimorbidity,
healthcare utilization, and quality of life for older patients undergoing surgery: A
prospective study. Medicine 2023;102:13(e33389).
Received: 10 November 2022 / Received in final form: 22 February 2023 /
Accepted: 8 March 2023
http://dx.doi.org/10.1097/MD.0000000000033389

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Thanakiattiwibun et al. • Medicine (2023) 102:13Medicine
of therapies and medical technologies, the need for healthcare
- especially in the older population - is becoming a significant
public health concern.[3–5]
The term “multimorbidity” is often defined as the coexis-
tence of 2 or more chronic conditions in the same person.[6–10] A
systematic review of older surgical patients found that 36% of
eligible patients had multimorbidity.[10] The high prevalence of
multimorbidity in older individuals (usually exceeding 60%)[3]
and the associated disproportional direct healthcare costs have
been demonstrated in previous studies.[4,5] More particularly,
multimorbidity was associated with increased healthcare uti-
lization (use of healthcare services). People use healthcare ser-
vices for many reasons.[11] They include preventing and curing
health problems, promoting the maintenance of health and
well-being, obtaining information about their health status and
prognoses,[8,12] decreasing functional competence,[13] a lowering
quality of life,[14] and increasing mortality rates.[15]
Currently, there are several assessment tools or criteria that
are relevant to the severity of comorbidity such as the Charlson
Comorbidity Index (CCI)[16] the Simple Frailty Questionnaire
(FRAIL)[17] and the American Society of Anesthesiologists’
(ASA) Physical Status Classification System. CCI categorizes
patients’ comorbidities based on the International Classification
of Diseases (ICD) diagnosis codes. Each comorbidity category
has associated scores (from 1 to 6) based on the adjusted risk
of mortality or resource use. The sum of the weights results in
a single comorbidity score for a patient,[18,19] is evolving, but
it is generally recognized as a state of decreased physiological
reserve.[20] The FRAIL questionnaire has drawn attention as a
clinical measure for the identification of the high-risk stratum of
the older population.[21] The ASA is a 6-point scale commonly
used as a measure of patients’ preoperative global health.[19,22]
The ASA system was developed in 1941[23] to establish a formal
system for classifying and evaluating patients’ general health
and comorbidities before operative procedures.[24] ASA scores
are typically assigned before procedures as a means of identify-
ing individuals who may be at increased risk for complications.
The scores have been shown to have predictive value in periop-
erative risk assessment, perioperative mortality and complica-
tion rates, and postoperative outcomes.[25–27]
The primary objective of this study was to investigate the
prevalence of multimorbidity. The secondary objectives were to
examine the effects of multimorbidity on healthcare utilization;
to examine the healthcare costs of multimorbidity; and to com-
pare the association between the healthcare-related quality of
life and multimorbidity, CCI, the FRAIL questionnaire, and the
ASA classification.
2. Materials and methods
2.1. Study design
This prospective cohort study was conducted at Siriraj Hospital,
Bangkok, Thailand, between May 2018 and December 2020.
Before its commencement, the protocol was approved by the
Siriraj Institutional Review Board (Si 182/2018). All patients
visiting the preoperative clinics were screened for protocol
enrollment. Before participation, all patient that satisfied all of
the selection criteria provided written informed consent.
2.2. Study population
The inclusion criteria were patients over 65 years old who were
scheduled for surgery and were undergoing preoperative eval-
uation and preparation. Participants with communication dif-
ficulties, such as language or hearing problems, were excluded.
In addition, patients whose operation were canceled or patients
who were lost to follow-up led to incomplete data were excluded
from the study analyses.
2
2.3. Measurement instruments and data collection
Preoperative patient characteristic data, including age, sex,
education level, province, and healthcare scheme, surgery site
(orthopedic, general, vascular, gynecologic), surgery type (major,
intermediate, minor), CCI, FRAIL questionnaire, and ASA clas-
sification (the ASA Physical Status Classification System is a
6-point scale commonly used to measure patients’ preoperative
global health)[19,22] were recorded onto data record forms.
Chronic diseases and multimorbidity was defined as the
presence of 2 or more chronic diseases co-occurring in the
same person.[6–10] Sixteen chronic diseases were examined: dia-
betes, cancer, chronic back pain, osteoarthritis, osteoporosis,
joint disease, allergies, chronic obstructive pulmonary disease,
dementia, schizophrenia, long-term antidepressant use, anxi-
ety, high cholesterol, hypertension, stroke, and heart disease
(Table S1, Supplemental Digital Content, http://links.lww.com/
MD/I722).[28]
Healthcare utilization has been defined as the quantification
or description of the use of services by individuals to prevent
and cure health problems and to promote the maintenance of
health and well-being.[12] The term encompasses the number of
preoperative visits, multiple-department consultations (mean-
ing of this study is patients who undergo surgery need to be
involved in specific consultations with more than 2 specialists
such as anesthesiology consultants at the preoperative clinic,
and/or medical consultation, subspecialist consultant (cardi-
ologist, pulmonologist), surgery waiting time, and hospital
length of stay.
Healthcare costs were collected by a research assistant
noted each preoperative appointment to enable the collection
of cost data from patients at every subsequent visit. The data
included out-of-pocket expenses, the number of companions,
and the income of both the patients and their companions.
The cost data included indirect medical cost (lost income was
calculated based on the income lost per day and the number
of workday absences of the patients and their companions);
direct nonmedical cost (the personal expenditures collected
were related to the transport, food, and accommodation
expenses for each hospital visit); and direct medical costs (we
obtained data on the medical costs for each visit from the hos-
pital Finance Department.)[29] The costs included laboratory
testing, chest X-rays, electrocardiography, medications, treat-
ment, and service fees). To exclude visits made for illnesses
not associated with the scheduled operation, we reviewed the
electronic medical records for each hospital visit from the
enrollment date until admission. All cost data are expressed
as Thai Baht.
Health-related quality of life (HRQoL) was derived from the
5-level EQ-5D (EQ-5D-5L) standard questionnaire developed
by the EuroQol group. According to Janssen,[30] the question-
naire has high sensitivity and precise measurement at the indi-
vidual and group levels in terms of descriptive system data and
utilities. The questionnaire has been translated and standard-
ized into a Thai version. It comprises 5 dimensions: mobility,
self-care, usual activities, pain/discomfort, and anxiety/depres-
sion. Patients are asked to choose the level of severity that best
corresponds with their current health status. The EQ-5D-5L
questionnaire was administered by trained research assistants
at multiple time points: on the preoperative visit day, admis-
sion day, and postoperatively at day 5, 1 month, and 3 months.
The EQ-5D-5L scores were calculated using the tariffs from
Thailand.[31]
2.4. Statistical analysis
The sample size estimate was based on a previously reported
prevalence of 36%[10] for multimorbidity among older surgical
patients. With a 5% error, a minimum sample size of 350 cases
was calculated.
Thanakiattiwibun et al. • Medicine (2023) 102:13www.md-journal.com

Sociodemographic and clinical variables were summarized by
using descriptive statistics. Continuous variables were described
as the mean and standard deviation or median and interquartile
range, depending on the data distribution. Categorical variables
were described as frequencies and percentages. Comparisons
between the comorbidity score <2 and ≥2 groups were per-
formed using the independent-samples t test or Mann–Whitney
U test for continuous variables and the chi-squared test or Fisher
exact test for categorical variables. The analyses were performed
using IBM SPSS Statistics for Windows (Version 28.0. Armonk,
NY: IBM Corp; 2021).
3. Results
From May 2018 to December 2020, 360 patients over 65 years
old underwent preoperative evaluations and preparations at
Siriraj Hospital. Their mean age was 73.96 ± 6.64 years, and
37.8% were men. The demographic and preoperative data of
the study population are detailed in Table 1.
3.1. Prevalence of multimorbidity
Among the 360 patients, 19 (5.3%), 56 (15.6%), 94 (26.1%),
104 (28.9%), 73 (20.3%), 12 (3.3%), and 2 (0.6%) subjects had
no, 1, 2, 3, 4, 5, and 6 comorbidities, respectively. Consequently,
multimorbidity was present in 285 (79%) of the patients (95%
CI, 74.6%–83.3%). The patients with multimorbidity had
significantly older than 75 years, and the majority of patients
(57.5%) were civil servant medical benefit schemes (Table 1).
3.2. Healthcare utilization with multimorbidity
The patients with multimorbidity had significantly greater
healthcare utilization than those without multimorbidity.
Relative to the patients without multimorbidity, the patients
with multimorbidity significantly had a higher proportion of
healthcare utilization which were the number of preoperative
visits (≥2 visits 259 [90.9%] patients) and needed for multi-
ple-department consultations, (≥2 departments 250 [87.7%]
patients) (Table 2).
3.3. Healthcare costs with multimorbidity
Table 3 presents the healthcare costs associated with multi-
morbidity. There was no significant difference between patients
with and without multimorbidity in terms of their direct medi-
cal costs at the preoperative visit, total direct nonmedical costs
at the preoperative visit, total indirect costs at the preoperative
visit, total direct nonmedical costs at admission, total indirect
operative costs, direct medical operative costs, and total cost.

Table 1
Demographic and preoperative medical profiles.
Variables Total (n = 360) Without multimorbidity (n = 75; 21%) With multimorbidity (n = 285; 79%) P value

Demographic data
 Age (yr) 73.96 ± 6.64 72.31 ± 6.15 74.39 ± 6.71 .015
   < 75 205 (56.9%) 53 (70.7%) 152 (53.3%) .009
   ≥ 75 155 (43.1%) 22 (29.3%) 133 (46.7%)
 Gender; male 136 (37.8%) 31 (41.3%) 105 (36.8%) .505
 Education level of patient .316
  Less than high school 175 (48.6%) 37 (49.3%) 138 (48.4%)
   High school 67 (18.6%) 10 (13.3%) 57 (20.0%)
   College 32 (8.9%) 10 (13.3%) 22 (7.7%)
  Advanced degrees 86 (23.9%) 18 (24.0%) 68 (23.9%)
 Province .080
   Capital 190 (52.8%) 31 (41.3%) 159 (55.8%)
  Outskirts of the capital 76 (21.1%) 19 (25.3%) 57 (20.0%)
   Rural 94 (26.1%) 25 (33.3%) 69 (24.2%)
 Health care scheme .017
  Civil servant medical benefit scheme 193 (53.6%) 29 (38.7%) 164 (57.5%)
  Universal coverage scheme 94 (26.1%) 25 (33.3%) 69 (24.2%)
   Self-pay 54 (15.0%) 15 (20.0%) 39 (13.7%)
  Social security scheme 14 (3.9%) 3 (4.0%) 11 (3.9%)
   Other 5 (1.4%) 3 (4.0%) 2 (0.7%)
 Companion for the preoperative visit .757
   No 41 (11.4%) 10 (13.3%) 31 (10.9%)
   1 person 204 (56.7%) 40 (53.3%) 164 (57.5%)
   ≥2 persons 115 (31.9%) 25 (33.3%) 90 (31.6%)
 Companion for the admission
   No 62 (17.2%) 14 (18.7%) 48 (16.8%)
   1 person 173 (48.1%) 38 (50.7%) 135 (47.4%)
   ≥2 persons 125 (34.7%) 23 (30.7%) 102 (35.8%)
Preoperative data
 Site of surgery .634
   Orthopedic 103 (28.6%) 19 (25.3%) 84 (29.5%)
   General 97 (26.9%) 20 (26.7%) 77 (27.0%)
  Vascular 83 (23.1%) 16 (21.3%) 67 (23.5%)
   Gynecologic 77 (21.4%) 20 (26.7%) 57 (20.0%)
 Type of surgery .223
   Major 247 (68.6%) 54 (72.0%) 193 (67.7%)
   Intermediate 57 (15.8%) 14 (18.7%) 43 (15.1%)
   Minor 56 (15.6%) 7 (9.3%) 49 (17.2%)
Data presented as number and percentage, or mean ± standard deviation.
ASA = American Society of Anesthesiologists’ physical status classification.

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Thanakiattiwibun et al. • Medicine (2023) 102:13Medicine

Table 2
The effect of healthcare utilization on multimorbidity.
Values
Variables Total (n = 360) Without multimorbidity (n = 75; 21%) With multimorbidity (n = 285; 79%) P value

Number of preoperative visits <.001

 1 visit 46 (12.8%) 20 (26.7%) 26 (9.1%)
 ≥2 visits 314 (87.2%) 55 (73.3%) 259 (90.9%)
Specific consultations .002
 1 specialist 56 (15.6%) 21 (28.0%) 35 (12.3%)
 ≥2 specialists 304 (84.4%) 54 (72.0%) 250 (87.7%)
Surgery waiting time (d) 49 (26–110) 53 (26–106) 47 (27–110) .949
Hospital length of stay (d) 4 (3–6) 4 (3–6) 4 (3–6) .358
Data are presented as number and percentage, or median and interquartile range.

Table 3
Healthcare costs of patients with multimorbidity and without multimorbidity.
Costs (Baht)
Variables Total (n = 360) Without multimorbidity (n = 75; 21%) With multimorbidity (n = 285; 79%) P value

Direct medical costs for preoperative 2899 (1645–4590) 2730 (1625–3893) 2935 (1700–4880) .313
visits (Baht)
Total direct nonmedical costs for 860 (483–1800) 800 (481–1900) 880 (484–1737 .866
preoperative visits (Baht)
 Travel costs (Baht/preoperative visit) 600 (250–1200) 500 (220–1273) 600 (280–1200) .977
 Accommodation costs (Baht/ 0 (0–3750) 0 (0–850) 0 (0–3750) .663
preoperative visit)*
 Food costs (Baht/preoperative visit) 200 (200–423) 210 (35–400) 200 (0–450) .721
Total indirect costs for preoperative visits 2263 (1005–4317) 2573 (1167–4500) 2653 (1240–4573) .647
(Baht)
 Lost income of patient (Baht/ 333 (57–667) 300 (33–667) 333 (57–667) .791
preoperative visit)
 Lost income of companion (Baht/ 800 (333–1333) 833 (463–1267) 733 (333–1333) .507
preoperative visit)
Total direct nonmedical costs at 300 (183–600) 343 (195–700) 300 (183–534) .483
admission (Baht)
 Travel costs (Baht/admission) 200 (100–500) 250 (100–550) 200 (100–500) .466
 Accommodation costs (Baht/ 0 (0–1350) 0 (0–1350) 0 (0–1000) .444
admission)*
 Food costs (Baht/day) 75 (33–123) 67 (39–104) 76 (33–124) .838
Total indirect operative costs (Baht) 4400 (2012–9045) 4500 (2030–8623) 4333 (2050–9060) .918
 Lost income of patient (Baht/ 1333 (267–3192) 1293 (140–3167) 1333 (300–3167) .529
operation)
 Lost income of companion (Baht/ 2667 (533–5833) 1500 (600–3200) 1800 (667–3000) .893
operation)
Direct medical operative costs (Baht) 40,768 (23,930–75,927) 38,581 (21,521–77,685) 40,951 (24,134–73,724) .716
Total cost (Baht) 57,336 (36,376–94,878) 56,760 (34,240–94,480) 57,510 (37,020–94,551) .938
Data are presented as number and percentage, or median and interquartile range.
*Accommodation data are presented as median (min—max).

3.4. HRQoL with multimorbidity, CCI, FRAIL, and ASA
The median HRQoL of patients with multimorbidity was signifi-
cantly lower than that of patients without multimorbidity upon
admission (0.87 vs 0.90; P = .010) and 3 months postoperatively
(0.96 vs 1.00; P = .007). Moreover, the median HRQoL of patients
with CCI scores ≥ 3 was significantly lower than that of patients
with CCI scores < 3 at day 5 (0.76; P = .022), 1 month (0.91; P =
.022), and 3 months (0.96; P = .003) postoperatively. Similarly, the
median HRQoL of patients with ASA Class > 2 was significantly
lower than that of patients with ASA Class ≤ 2 at day 5 (0.76; P
= .018), 1 month (0.90; P = .001), and 3 months (0.96; P < .001)
postoperatively. In contrast, there were no significant differences
in the HRQoL of patients with < 5 illnesses and those with ≥ 5
illnesses when assessed by the FRAIL questionnaire (Table 4).
The EQ-5D-5L questionnaire results are detailed in Table 5.
It can be seen from Figure 1 that HRQoL tended to worsen over
the 3-month postoperative period. The most noticeable decrease
in HRQoL was shown by patients with higher levels of multi-
morbidity, especially those with ≥4 chronic illnesses.
4. Discussion
4.1. Prevalence of multimorbidity
Siriraj Hospital is Thailand largest university hospital. Our
analysis revealed that the preoperative prevalence of multimor-
bidity in the hospital older surgical patients (aged > 65 years)
was 79.2% (95% CI, 74.6%–83.3%). Our rate is similar to
the prevalence of multimorbidity reported by previous studies.
There was a study on older emergency general surgical patients
found an overall rate of 74% (95% CI, 69.7%–78.2%), with
multimorbidity prevalence increasing with age over 65.[32] This
rate is comparable with our result. In addition, Borsari et al[33]

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Thanakiattiwibun et al. • Medicine (2023) 102:13www.md-journal.com

Table 4
Associations between health-related quality of life and multimorbidity, CCI, FRAIL questionnaire, and ASA classification.
Chronic conditions CCI scores FRAIL scores ASA classification
(n = 360) (n = 360) (n = 360) (n = 360)
Without With ≥5
multimorbidity; multimorbidity; P <3; 192 ≥3; 168 P <5 illnesses; illnesses; 7 P Class ≤2; Class >2; P
HRQoL 75 (20.8%) 285 (79.2%) value (53.3%) (46.7%) value 353 (98.1%) (1.9%) value 175 (48.6%) 185 (51.4%) value

Preoperative 0.90 0.87 .096 0.89 0.88 .120 0.89 0.85 .368 0.90 0.86 .080
visits (0.77–0.96) (0.70–0.94) (0.74–0.96) (0.65–0.94) (0.71–0.96) (0.76–0.87) (0.74–0.96) (0.70–0.94)
At admission 0.90 0.87 .010 0.87 0.87 .200 0.87 0.81 .288 0.89 0.85 .078
(0.81–0.97) (0.71–0.93) (0.74–0.96) (0.71–0.93) (0.73–0.96) (0.80–0.83) (0.74–0.96) (0.72–0.93)
Postoperative d 5 0.83 0.77 .108 0.83 0.76 .022 0.80 0.75 .969 0.83 0.76 .018
(0.71–0.91) (0.60–0.89) (0.67–0.92) (0.56–0.88) (0.62–0.90) (0.63–0.89) (0.67–0.91) (0.57–0.88)
1-mo follow-up 0.96 0.93 .144 0.94 0.91 .022 0.93 0.90 .730 0.96 0.90 .001
(0.87–1.00) (0.83–1.00) (0.87–1.00) (0.80–1.00) (0.83–1.00) (0.87–0.94) (0.87–1.00) (0.80–0.97)
3-mo follow-up 1.00 0.96 .007 1.00 0.96 .003 0.96 0.96 .768 1.00 0.96 <.001
(0.95–1.00) (0.87–1.00) (0.93–1.00) (0.87–1.00) (0.90–1.00) (0.94–1.00) (0.92–1.00) (0.87–1.00)
Data are presented as median and interquartile range. Quality of life assessment by EuroQoL group—5 Dimensions—5 Levels (EQ-5D-5L).
ASA = American Society of Anesthesiologists’ physical status classification; CCI = the Charlson Comorbidity Index; FRAIL = the illness domain of the Simple Frailty Questionnaire; HRQoL = health-related
quality of life.

Table 5
Problems with health-related quality of life reported by respondents 3 months postoperatively via the 5 dimensions of EuroQol
5-dimension 5-level (EQ-5D-5L) questionnaire.
Values
Dimensions Total (n = 360) Without multimorbidity (n = 75; 21%) With multimorbidity (n = 285; 79%) P value

Mobility; n (%) .105

 No problems 245 (68.1%) 59 (78.7%) 186 (65.3%)
 Slight problems 78 (21.7%) 14 (18.7%) 64 (22.5%)
 Moderate problems 24 (6.7%) 1 (1.3%) 23 (8.1%)
 Severe problems 8 (2.2%) 1 (1.3%) 7 (2.5%)
 Unable to walk about 5 (1.4%) 0 5 (1.8%)
Self-care; n (%) .296
 No problems 291 (80.0%) 67 (89.3%) 224 (78.6%)
 Slight problems 47 (13.1%) 6 (8.0%) 41 (14.4%)
 Moderate problems 13 (3.6%) 1 (1.3%) 12 (4.2%)
 Severe problems 6 (1.7%) 1 (1.3%) 5 (1.8%)
 Unable to wash or dress myself 3 (0.8%) 0 3 (1.1%)
Usual activities; n (%) .054
 No problems 277 (76.9%) 67 (89.3%) 210 (73.7%)
 Slight problems 57 (15.8%) 4 (5.3%) 53 (18.6%)
 Moderate problems 19 (5.3%) 3 (4.0%) 53 (18.6%)
 Severe problems 5 (1.4%) 1 (1.3%) 4 (1.4%)
 Unable to do 2 (0.6%) 0 2 (0.7%)
Pain/discomfort; n (%) .583
 No pain 247 (68.6%) 55 (73.3%) 192 (67.4%)
 Slight pain 101 (28.1%) 19 (25.3%) 82 (28.8%)
 Moderate pain 8 (2.2%) 1 (1.3%) 7 (2.5%)
 Severe pain 4 (1.1%) 0 4 (1.4%)
 Extreme pain 0 0 0
Anxiety/depression; n (%) .166
 Not anxious or depressed 277 (76.9%) 65 (86.7%) 212 (74.4%)
 Slightly 60 (16.7%) 7 (9.3%) 53 (18.6%)
 Moderately 16 (4.4%) 2 (2.7%) 14 (4.9%)
 Severely 7 (1.9%) 1 (1.3%) 6 (2.1%)
 Extremely 0 0 0
Data presented as number and percentage.

conducted a retrospective observational study to assess the
prevalence of multimorbidity (20.1%) in patients aged 65 years
or older who underwent surgery for femoral neck fractures at
an orthopedic institute, which is consistent with our findings at
our own orthopedic surgery site, where the prevalence of multi-
morbidity was 29.5%.
An understanding of the epidemiological characteristics and
the implications of multimorbidity is necessary for better risk
stratification of multimorbidity. It also enables integrated coor-
dination of multiple patient appointments and more effective
communication among healthcare professionals, resulting in
better management of patients’ varied clinical needs.

5
Thanakiattiwibun et al. • Medicine (2023) 102:13Medicine
Figure 1. Relationship between multimorbidity and health-related quality of life.
4.2. Healthcare utilization with multimorbidity
Multimorbidity is associated with very high healthcare utiliza-
tion. A clear understanding of the current burden of multimor-
bidity is fundamental for managing patients in health service
delivery systems and healthcare policy debates about resource
allocation. Strategies for better coordination of patients with
multimorbidity are urgently needed.[34]
The study showed high healthcare utilization (in terms of the
number of preoperative visits and multiple-department consul-
tations). In line with our results, Starfield et al[35] determined
that the number of visits by the nonolder population to primary
care physicians and specialists was highly associated with the
degree of comorbidity. A high number of referrals to specialists
was found by a Dutch survey as well.[36] Likewise, a high burden
of diseases was associated with high referrals of US Medicare
beneficiaries aged 65 or older to specialists.[37] High levels were
even found in patients with very common chronic diseases that
primary care physicians typically manage. According to a study
by Romana et al,[38] patients with multimorbidity often used
primary healthcare consultations, as well as consultations with
medical or surgical specialist and hospitalizations. Another pre-
vious observational study by Fortuna et al reported the impact
on healthcare resources use was significant, with around 70%
of all provided healthcare services provided being allocated to
elderly patients with multimorbidity.[11]
4.3. Healthcare costs with multimorbidity
The relationship between multimorbidity and healthcare costs,
particularly the magnitude, may vary not only by person-spe-
cific and environmental factors (such as frailty, income depri-
vation, or availability of social care services) but also across
health systems.[39,40] Our study showed that the following were
higher for patients with multimorbidity than for patients with-
out multimorbidity: direct medical costs for preoperative visits,
direct nonmedical costs for preoperative visits, indirect costs
for preoperative visits, direct nonmedical costs upon admis-
sion, indirect operative costs, direct medical operative costs.
However, in our results the healthcare costs there were no
significant differences between the patients with and without
multimorbidity. In this study, the majority of patients (57.5%)
were covered with in the Civil Servant Medical Benefit Scheme
(CSMBS), which provides healthcare benefits to government
officials and their dependents in Thailand. Both CSMBS and
the Universal Coverage Scheme (UCS) were managed by the
6
Comptroller General Department of the Ministry of Finance.
Although the expenses issued by the Comptroller General
Department were included, along with additional payments in
excess of the right to treatment, it was found that the healthcare
costs for patients who self-pay may be higher than those with
CSMBS and UCS coverage. Consistent with Harnphadungkit
K, et al,[41] who investigated hospital charges and Diagnosis
Related Groups payments for inpatients at Siriraj Hospital,
the service payments received from the Comptroller General
Department were consistently lower than the amount charged
by the hospital for the services provided. Given that, more than
half of enrolled patients in this study were in the CSMBS and
UCS programs so there was no significant difference in health-
care costs between those with and without multimorbidity.
Unlike several previous studies, the multimorbidity was sig-
nificantly associated with increased total costs, hospital costs,
care transition costs, primary care use,[40,42] and out-of-pocket
healthcare expenditure,.[43] This is particularly problematic
for individuals with multiple conditions and lower incomes,
as they may face significant financial burdens in accessing the
healthcare services they need. Therefore, the impact of multi-
morbidity on costs extends beyond insurers and government
funding of healthcare systems to individual patients, given
that patients directly experience out-of-pocket costs associated
with their medical treatment.[44–46]
4.4. HRQoL with multimorbidity, CCI, FRAIL, and ASA
Advances in perioperative management and surgical techniques
in older patients have reduced postoperative complications.
Nevertheless, challenges remain among older patients due to
their decreased functional reserve, increased frailty, relatively
large number of comorbidities, reduced quality of life, and
increased mortality.[47] It is therefore essential to identify high-
risk older patients during the preoperative period.
This study showed that among patients with multimorbidity,
CCI and ASA Class were associated with a reduced postopera-
tive HRQoL. The CCI and ASA classification systems have been
used in the literature to assess risk preoperatively. Although both
measures have been positively correlated with expected postop-
erative HRQoL, the ASA system showed a stronger association
with HRQoL than the CCI. In the present investigation, patients
with ASA Class > 2 had a significantly lower median HRQoL
than those with ASA Class ≤2 at day 5, 1 month, and 3 months
postoperatively. This result supports the utility of the ASA classi-
fication system as a comorbidity index for older surgical patients.
Thanakiattiwibun et al. • Medicine (2023) 102:13www.md-journal.com
The ASA system was developed to formally classify and eval-
uate patients’ general health and comorbidities before operative
procedures.[24] The system uses a 6-point classification scale,[19,22]
and ASA classes are typically assigned before procedures to identify
individuals at increased risk for complications. The ASA system has
been shown to have predictive value in perioperative risk assess-
ment, perioperative mortality and complication rates, and postop-
erative outcomes.[25–27] In addition, a previous study reported that
ASA classes are more closely associated with the rate of major com-
plications than CCI scores. This finding may reflect the advantage
of the subjective assessments of the ASA classification system com-
pared with the rigid calculation of the CCI. CCI assessments may
fail to adequately assess some patient comorbidities that are likely
to contribute to major complications.[19] The ASA classes also act
as an indicator of total inpatient costs and length of stay. Since ASA
classification is a universally collected data point, it can be used in
almost any hospital system and for any operative service.[25]
4.5. Strengths and limitations
This is one of the few studies in Thailand to have investigated
the association between multimorbidity and healthcare utiliza-
tion and costs for older surgical patients. Our findings reflect the
actual situation in a real-world setting. Data with reliable infor-
mation on healthcare utilization and costs were used to calculate
the proportion of individuals with multimorbidity and its asso-
ciated factors. The health-related quality of life was assessed by
the EQ-5D-5L questionnaire. The EQ-5D-5L questionnaire was
the standard value set, as this was produced with the EuroQol
Group standardized valuation study protocol (called EQ-VT).
Based on registry data, our study was free of recall bias, and
there was no loss to follow-up.
There are some limitations to our study. First, the loss of
income per day was estimated for participants with no constant
wage or salary, such as self-employed individuals. In addition,
as some participants could not provide an exact income level,
they only gave an approximation. Second, the direct nonmed-
ical cost in our study was not collected for healthcare costs at
1 month and 3 months postoperatively. Third, in our study,
we excluded patients who canceled their operation due to the
unavailability of surgery cost data and who had communica-
tion difficulties/hearing loss because of the difficulty to receive
information regarding functional outcomes. We recognize that
this may introduce a potential bias in the data, as it is possible
that patients who canceled their operation for cost reasons may
have been more likely to experience financial difficulties or lack
adequate healthcare coverage. Additionally, we were unable to
assess the quality of life of patients who missed follow-up. This
may introduce a further limitation to our study, as the quality of
life is an important outcome measure that can impact patients’
overall healthcare experience. Finally, the small sample size and
the fact that this study focused solely on older surgical patients
in a university hospital, the results may not be generalizable to
other populations and could potentially be biased.
Despite these limitations, we believe our study provides valu-
able insights into the prevalence of multimorbidity in older
surgical patients and the associated healthcare costs. However,
we acknowledge the possibility of bias in the interpretation of
cost data, which we have included in our manuscript. Moving
forward, we recommend that future research considers these
limitations and seeks to address them where possible. By doing
so, we can further advance our understanding of the impact of
multimorbidity on healthcare utilization and costs, and work
towards improving access to care for all patients.
5. Conclusions
In conclusion, our study revealed that older surgical patients
with multimorbidity had significantly increased healthcare
7
utilization and reduced health-related quality of life during hos-
pital admission and postoperatively. The ASA classification was
identified as a potential indicator of reduced HRQoL at day 5,
1 month, and 3 months postoperatively, highlighting the need
for preventive services. Geriatric patients with multimorbidity
require special consideration, leading to the development of pol-
icy for better resource management for this population.
Acknowledgments
The authors gratefully acknowledge the patients who gener-
ously agreed to participate in this study and Assistant Professor
Dr Chulaluk Komoltri, M.P.H. (Biostatistics) a statistician,
for her assistance with the statistical analyses and Mr Monai
Sauejui for contribution to the administrative tasks. The authors
are also indebted to Mr David Park for the English-language
editing of this paper.
Author contributions
Conceptualization: Arunotai Siriussawakul.
Data curation: Chayanan Thanakiattiwibun, Tithita
Virotjarumart, Satanun Maneeon, Narisa Tantai.
Formal analysis: Chayanan Thanakiattiwibun, Tithita
Virotjarumart, Satanun Maneeon, Narisa Tantai.
Funding acquisition: Arunotai Siriussawakul.
Methodology: Arunotai Siriussawakul.
Project administration: Chayanan Thanakiattiwibun.
Supervision: Arunotai Siriussawakul, Varalak Srinonprasert,
Onuma Chaiwat, Patcharee Sriswasdi.
Validation: Arunotai Siriussawakul, Varalak Srinonprasert,
Onuma Chaiwat, Patcharee Sriswasdi.
Writing – original draft: Chayanan Thanakiattiwibun, Arunotai
Siriussawakul, Tithita Virotjarumart.
Writing – review & editing: Chayanan Thanakiattiwibun,
Arunotai Siriussawakul, Onuma Chaiwat.
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