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Author Archives: Cynthia Boyd

OUR WELCOME POST: US Deprescribing Research Network

By Cynthia Boyd and Mike Steinman

Though medications offer the capacity to extend lives, relieve symptoms, and reduce the feared consequences of disease, they can also cause bothersome and dangerous side effects, burden older adults and their caregivers, and deplete savings. The use of multiple prescription drugs among U.S. adults age 65 and older has increased from 24% in 2000 to 39% in 2012. This significant growth is attributable to a growing older population, onset of chronic disease, and increasing availability of drugs for treatment and prevention. So, how do we handle the double-edged sword that is medication-treatment? By understanding and identifying the medications that are suitable for each patient, and deprescribing those for which these harms outweigh the benefit.

What is deprescribing? Deprescribing refers to the thoughtful and systematic process of identifying problematic medications and either reducing the dose or stopping the medication in a manner that is safe, effective, and helps people maximize their health and wellness goals.

However, this process is not easy. Little is known about how to best identify which medications are prime for deprescribing, how to safely and effectively stop them, and how to engage older adults, their loved ones, clinicians, and the health system in this process in a seamless and person-centered manner.

The National Institute on Aging recognizes the need for deprescribing medications among older adults and has awarded a five-year, $6.2 million grant to the University of California, San Francisco (UCSF) and Johns Hopkins University to establish the U.S. Deprescribing Research Network (USDeN).

Who we are and what we do – The USDeN is led by Co-Principal Investigators Michael Steinman, MD, at UCSF and the San Francisco VA Medical Center, and Cynthia Boyd, MD, MPH, at Johns Hopkins University School of Medicine. The network is comprised of a community of individuals who share the common goal of developing and disseminating high-quality evidence about deprescribing for older adults, and in doing so, helping improve medication use among older adults and the outcomes that are important to them.

The network’s key activities are designed to provide resources and create a central place for mutual learning, collaboration, building research capacity, and catalyzing work among a large and multidisciplinary group of investigators. Network activities are oriented around 4 cores and a series of working groups:

Investigator Development Core – Organizes activities to provide education and collaboration about deprescribing research, with a special focus on the needs of early-stage investigators.

Pilot and Exploratory Studies Core – Funds and supports pilot and grant planning studies related to deprescribing for older adults.

Stakeholder Engagement Core – Supports engagement of patients, caregivers, clinicians, and health system stakeholders with various activities of the network, so that the resulting research is maximally responsive to their priorities and needs.

Data and Resources Core – Provides information about prior and ongoing research on deprescribing, research resources relevant to deprescribing, and will build capacity for the use of existing electronic health record data for deprescribing research

Working Groups – Supports 4 working groups that will synthesize existing research and develop new tools for deprescribing research, including identifying high-priority targets for deprescribing, optimizing measurement tools and using electronic health data in deprescribing research, and optimizing communication around deprescribing.

We invite you to join our community of innovators by visiting us at https://deprescribingresearch.org, and following us on Twitter @DeprescribeUS. For more information contact admin@deprescribingresearch.org.

Cross-posted at https://deprescribingresearch.org/our-welcome-post-us-deprescribing-research-network/

Improving Guidelines for Multimorbid Patients

By Cynthia M. Boyd and David M. Kent

With rare exceptions, guidelines focus on the management of a single disease, or a single disease-problem, and do not address how to optimally integrate care for individuals whose multiple problems may make guideline-recommended management of any single disease impractical, irrelevant or even harmful.  Current standards of guideline development or appraisal do not prompt guideline developers to routinely address the issue that not all patients with the same condition benefit similarly from similar therapy, nor do they provide tools for adapting the recommendations to the patient with many diseases or for prioritizing the most important recommendations within a single disease, let alone between diseases. The root of this problem, however, is not narrowly confined to guideline development and implementation. At each phase of the translational path including trial and study design and analysis, the synthesis of trial and observational study results in meta-analyses and systematic reviews, and the guideline development process, the very information necessary to support evidence-based care of the person with multimorbidity is excluded.  Needed, then, is a comprehensive approach built on a firm understanding of each of these phases of evidence generation, synthesis and integration, and guideline development. 

To address these issues, we assembled a collaborative team with complementary expertise spanning the various phases of evidence development and translation to develop a comprehensive description of the problem and provisional recommendations.  These were refined through an iterative process of feedback from researchers (from medicine, public health, biostatistics), guideline developers, and stakeholders from government, other payers and industry, which culminated at a conference on Improving Guidelines for Multimorbid Patients (Baltimore, Maryland October 2010). The results of this project are presented in 4 papers [1-4] in a symposium in the Journal of General Internal Medicine, focused on the following 3 areas: 1) evidence generation (clinical trial and observational study design and analysis), 2) evidence synthesis (systematic review, meta-analyses) and 3) guideline development.


1. Boyd CM and Kent DM. Evidence-Based Medicine and the Hard Problem of Multimorbidity. JGIM 2014 Jan 18. [Epub ahead of print].
2. Weiss CO, Varadhan R, Puhan M, Vickers A, Bandeen-Roche K, Boyd CM, Kent  DM. Multimorbidity and Evidence Generation, JGIM 2014 Jan 18. [Epub ahead of print].
3. Trikalinos T, Segal J, Boyd CM. Addressing Multimorbidity in Evidence Synthesis and Integration., JGIM 2014 Jan 18. [Epub ahead of print].
4. Uhlig K, Leff B, Kent DM, Dy S, Brunnhuber K, Burgers J, Greenfield S, Guyatt G, High K, Leipzig R, Mulrow C, Schmader K, Schunemann H, Walter L, Woodcock J, and Boyd CM. A framework for crafting clinical practice guidelines that are relevant to the care and management of people with multimorbidity. JGIM 2014 Jan 18. [Epub ahead of print].

Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society

By Cynthia Boyd

A new report issued by the American Geriatrics Society (AGS) outlines how clinicians can tailor care to better meet the unique needs older adults with multimorbidity.  More than half of adults 65 and older have at least three chronic conditions, such as heart disease, diabetes, and arthritis.

Entitled Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society, the new report was published in today’s early, online edition of the Journal of the American Geriatrics Society (JAGS) and is available at www.americangeriatrics.org, in conjunction with a longer version of the documents with more complete references.  A wealth of related information, tips, and tools for both clinicians and the public are also available on the AGS website.

To help both clinicians and patients make complex treatment decisions, the expert panel that developed the report has outlined five essential elements, or guiding principles, for quality care for older adults with multimorbidity: 

  • Preferences: Elicit and incorporate patient preferences* into medical decision-making for older adults with multimorbidity.

By using the term “patient” preferences, we aim to keep the patient central to the decision-making process while recognizing that family and social supports play a vital role in management and decision-making whether or not cognitive impairment is present.

  • Interpreting the evidence: Recognizing the limitations of the evidence base, interpret and apply the medical literature specifically to older adults with multimorbidity.
  • Prognosis: Frame clinical management decisions within the context of risks, burdens, benefits, and prognosis (e.g. remaining life expectancy, functional status, quality of life) for older adults with multimorbidity.
    • Clinical Feasibility: Consider treatment complexity and feasibility when making clinical management decisions for older adults with multimorbidity.
    • Optimizing Therapies and Care Plans: Utilize strategies for choosing therapies that optimize benefit, minimize harm, and enhance quality of life for older adults with multimorbidity.

    The report also describes the urgent need for research to develop and implement evidence-based practices for each of these areas.

    Cynthia Boyd, MD MPH
    Associate Professor of Medicine
    Division of Geriatric Medicine and Gerontology
    Johns Hopkins University School of Medicine