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Framework for Evaluating Disease Severity Measures in Older Adults With Comorbidity

¹ Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
² Center on Aging and Health, Johns Hopkins Medical Institutions, Baltimore, Maryland.
³ Division of Geriatric Medicine and Institute of Gerontology, University of Michigan, Ann Arbor.
⁴ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
⁵ Institute for Advanced Studies in Aging, Washington, D.C.

Address correspondence to Cynthia M. Boyd, MD, MPH, Johns Hopkins University School of Medicine, Center on Aging and Health, Mason F. Lord Building, 7th floor, Center Tower, 5200 Eastern Avenue, Baltimore, MD 21224. E-mail: cyboyd{at}jhmi.edu

Background. Accounting for the influence of concurrent conditions on health and functional status for both research and clinical decision-making purposes is especially important in older adults. Although approaches to classifying severity of individual diseases and conditions have been developed, the utility of these classification systems has not been evaluated in the presence of multiple conditions.

Methods. We present a framework for evaluating severity classification systems for common chronic diseases. The framework evaluates the: (a) goal or purpose of the classification system; (b) physiological and/or functional criteria for severity graduation; and (c) potential reliability and validity of the system balanced against burden and costs associated with classification.

Results. Approaches to severity classification of individual diseases were not originally conceived for the study of comorbidity. Therefore, they vary greatly in terms of objectives, physiological systems covered, level of severity characterization, reliability and validity, and costs and burdens. Using different severity classification systems to account for differing levels of disease severity in a patient with multiple diseases, or, assessing global disease burden may be challenging.

Conclusions. Most approaches to severity classification are not adequate to address comorbidity. Nevertheless, thoughtful use of some existing approaches and refinement of others may advance the study of comorbidity and diagnostic and therapeutic approaches to patients with multimorbidity.

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