Multimorbidity burden and hospitalisation outcomes in heart failure: a retrospective cohort study using Indonesian national health insurance claims data (2019-2024).
Multimorbidity is highly prevalent among patients hospitalised with heart failure in Indonesia and is associated with longer length of stay and higher 30-day and 90-day readmission odds, with distinct comorbidity patterns observed across outcomes.
Key Findings
Results
Multimorbidity was present in nearly three-quarters of patients hospitalised with heart failure in Indonesia.
72.4% of patients had multimorbidity (defined as at least one comorbidity beyond heart failure)
The study included 9018 patients contributing 12,461 HF episodes
Mean patient age was 59.8 ± 13.1 years; 51.4% were male
12 prespecified comorbidities were ascertained from all available claims data
Data were drawn from Indonesia's national health insurance programme (BPJS Kesehatan) spanning 2019–2024
Results
Each additional comorbidity beyond heart failure was independently associated with longer length of hospital stay.
Each additional comorbidity was associated with β 0.13 days longer LOS (95% CI 0.03 to 0.22)
Analysis used survey-weighted linear regression adjusted for age and sex
The study used probability-weighted administrative claims to ensure national representativeness
Anaemia showed the strongest individual comorbidity association with prolonged LOS
Results
Each additional comorbidity was associated with significantly higher odds of both 30-day and 90-day heart failure-specific readmission.
Each additional comorbidity was associated with OR 1.22 for 30-day readmission (95% CI 1.07 to 1.38)
Each additional comorbidity was associated with OR 1.27 for 90-day readmission (95% CI 1.14 to 1.42)
Analysis used survey-weighted logistic regression adjusted for age and sex
Readmission outcomes were defined as HF-specific readmissions within 30 and 90 days
Results
Distinct individual comorbidities were associated with readmission outcomes, differing from those most strongly associated with length of stay.
Ischaemic heart disease, chronic kidney disease, chronic obstructive pulmonary disease, and valvular disease were associated with readmission
Anaemia showed the strongest association with prolonged LOS rather than readmission
These distinct patterns suggest different pathophysiological mechanisms drive LOS versus readmission
12 prespecified comorbidities were evaluated across both outcome types
Background
This study provides nationally representative evidence on multimorbidity and heart failure hospitalisation outcomes from a low- and middle-income country setting.
Most prior evidence on multimorbidity and HF outcomes originates from older populations in high-income countries
Data were drawn from BPJS Kesehatan, Indonesia's national health insurance programme, using probability-weighted administrative claims
The study covered a five-year period from 2019 to 2024
The population-based retrospective cohort design used nationally representative sampling
Conclusions
The findings suggest a need for health systems in Indonesia and similar LMIC settings to better account for multimorbidity in heart failure care.
Both multimorbidity burden and specific comorbidities were associated with adverse hospitalisation outcomes
The authors conclude there is 'a need for health systems that better account for multimorbidity'
The context of expanding universal health coverage in LMICs is identified as relevant to interpreting these findings
The study notes that heart failure frequently coexists with multimorbidity, which is associated with worse hospitalisation outcomes
What This Means
This research used five years of Indonesian national health insurance claims data to examine how having multiple chronic conditions (multimorbidity) affects hospital outcomes for people admitted with heart failure. The study found that nearly three out of four heart failure patients had at least one additional chronic condition, and having more conditions was linked to spending longer in hospital and being more likely to be readmitted within 30 or 90 days. Specifically, each extra condition was associated with about an eighth of a day longer hospital stay and roughly a 22–27% higher chance of readmission, depending on the timeframe.
The research also found that different conditions mattered for different outcomes. Anaemia was most strongly linked to longer hospital stays, while conditions like ischaemic heart disease (blocked coronary arteries), chronic kidney disease, chronic obstructive pulmonary disease, and valvular heart disease were more strongly associated with being readmitted to hospital. This suggests that the reasons patients stay longer versus the reasons they return to hospital may be driven by different underlying health problems.
This research matters because most previous studies on this topic have come from wealthy countries with older populations, leaving a gap in understanding for lower- and middle-income countries like Indonesia, which is rapidly expanding healthcare coverage while facing a growing burden of chronic disease. The findings suggest that healthcare systems in Indonesia and similar settings may need to develop better strategies to manage patients with multiple chronic conditions alongside heart failure, potentially reducing avoidable hospital stays and readmissions.
Yolanda G, Damarkusuma A. (2026). Multimorbidity burden and hospitalisation outcomes in heart failure: a retrospective cohort study using Indonesian national health insurance claims data (2019-2024).. Open heart. https://doi.org/10.1136/openhrt-2026-004340