Article Text

Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System
  1. Donna M Zulman1,2,
  2. Christine Pal Chee1,3,
  3. Todd H Wagner1,3,4,
  4. Jean Yoon1,3,
  5. Danielle M Cohen2,
  6. Tyson H Holmes5,
  7. Christine Ritchie6,7,
  8. Steven M Asch1,2
  1. 1Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
  2. 2Division of General Medical Disciplines, Stanford University, Stanford, California, USA
  3. 3Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
  4. 4Health Research and Policy, Stanford University, Stanford, California, USA
  5. 5Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
  6. 6Division of Geriatrics, University of California, San Francisco, California, USA
  7. 7San Francisco VA Medical Center, San Francisco, California, USA
  1. Correspondence to Dr Donna M Zulman; dzulman{at}


Objectives To investigate the relationship between multimorbidity and healthcare utilisation patterns among the highest cost patients in a large, integrated healthcare system.

Design In this retrospective cross-sectional study of all patients in the U.S. Veterans Affairs (VA) Health Care System, we aggregated costs of individuals’ outpatient and inpatient care, pharmacy services and VA-sponsored contract care received in 2010. We assessed chronic condition prevalence, multimorbidity as measured by comorbidity count, and multisystem multimorbidity (number of body systems affected by chronic conditions) among the 5% highest cost patients. Using multivariate regression, we examined the association between multimorbidity and healthcare utilisation and costs, adjusting for age, sex, race/ethnicity, marital status, homelessness and health insurance status.

Setting USA VA Health Care System.

Participants 5.2 million VA patients.

Measures Annual total costs; absolute and share of costs generated through outpatient, inpatient, pharmacy and VA-sponsored contract care; number of visits to primary, specialty and mental healthcare; number of emergency department visits and hospitalisations.

Results The 5% highest cost patients (n=261 699) accounted for 47% of total VA costs. Approximately two-thirds of these patients had chronic conditions affecting ≥3 body systems. Patients with cancer and schizophrenia were less likely to have documented comorbid conditions than other high-cost patients. Multimorbidity was generally associated with greater outpatient and inpatient utilisation. However, increased multisystem multimorbidity was associated with a higher outpatient share of total costs (1.6 percentage points per affected body system, p<0.01) but a lower inpatient share of total costs (−0.6 percentage points per affected body system, p<0.01).

Conclusions Multisystem multimorbidity is common among high-cost VA patients. While some patients might benefit from disease-specific programmes, for most patients with multimorbidity there is a need for interventions that coordinate and maximise efficiency of outpatient services across multiple conditions.


This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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