Editorials

Introducing POEMs

ALLEN F. SHAUGHNESSY, PHARM.D.
Harrisburg Family Practice Residency
Pennsylvania

JAY SIWEK, M.D.
Georgetown University Medical Center, Washington, D.C.

In this issue of American Family Physician, we are pleased to introduce an ongoing feature called POEMs, a series that may already be familiar to many of our readers. The acronym POEMs, which stands for Patient-Oriented Evidence that Matters, refers to summaries of valid research that are important to physicians and to their patients. Ideally, POEMs represent information that has the potential to change the way physicians practice medicine.

Many of us suffer from "information overload" because there simply is too much new medical information available to process. The POEMs concept provides a filtering system, screening out most research findings and leaving only information that is correct and relevant to everyday practice.

What type of study qualifies for a POEM? A POEM is valid research that answers "yes" to the following three questions:

• Did the research focus on an outcome that patients care about (e.g., morbidity, mortality, quality of life)?
• Is the problem that has been studied common and is the intervention feasible?
• Does the information have the potential to change the practice of many physicians?

The most important aspect of a POEM is that it provides information that matters to our patients. Patients come to us with the understanding that what we do for them, or what we ask them to do, will help them to live longer, better, or both. Our goal is to do just that.

However, much of the information available to us in medical journals is on the pathophysiology, etiology, and prevalence of disease, and on the mechanism of action of drugs. While this information is often helpful, it may or may not help us to do what is best for our patients. This information told us that hormone replacement therapy lowers low-density lipoprotein cholesterol levels in women, that short-acting calcium channel blockers lower blood pressure, and that the cyclo-oxygenase-2 (COX-2) inhibitors selectively inhibit inflammatory mechanisms of the COX-2 isoenzyme while preserving mucosal integrity. All of these intermediate findings were determined to be misleading when new, better-designed trials reported on patient-oriented outcomes. These POEMs contradicted the earlier information that focused on disease processes rather than relevant outcomes.

POEMs come from research published in more than 100 clinical journals. Each month a team of family physicians and educators comb through this literature looking for results that are relevant and immediately applicable to practice. Potentially relevant research findings are identified and evaluated for validity (www.infopoems.com/informationmastery.cfm). The valid POEMs are summarized, reviewed, revised, and compiled into InfoRetriever, part of the InfoPOEMs Clinical Awareness System (www.InfoPOEMs.com).

POEMs are similar to AFP's "Tips from Other Journals" department in that they summarize research articles from other journals. Both share similar purposes, namely to update family physicians on important new developments in common clinical problems and provide information that physicians can use in day-to-day practice. But, how do they differ? For one thing, the criteria for "Tips" are somewhat broader than the criteria for POEMs. Tips may include tables and figures from the original article. On the other hand, POEMs are derived from a larger number of journals, they are more likely to cover the most clinically important, outcomes-oriented research findings, and they undergo strict validity assessment of the research. These findings are presented in a structured format, including a level-of-evidence score, and are always accompanied by an editorial commentary (see the accompanying table).

TABLE 1 Comparison of Tips and POEMs Criteria Tips POEMs Discusses a common clinical problem in family practice Yes Yes Reports on a new development Yes Yes Provides practical pointers for day-to-day practice Yes Yes Allows focus on pathophysiology, etiology, basic science Yes No Allows summary of review article Yes No Has a rigorous methodology for article selection No Yes Specifies levels of evidence for the research design No Yes Focuses on clinically important outcomes (e.g., morbidity, mortality, quality of life) Optional Required Presented in an explicit, structured format No Yes Includes tables, figures from the original article Occasionally Rarely Provides editorial commentary Occasionally Always Number of journals reviewed 30 to 60 100 Written by family physicians and family practice educators Yes Yes

Each issue of AFP will feature four or more POEMs, some taking the place of Tips. If our readers find these useful, the number will increase. We hope you will read and enjoy the POEMs in each issue and will take a moment to give us your feedback.

Allen F. Shaughnessy, Pharm.D., is a contributing editor to American Family Physician; senior medical editor, InfoPOEM, Inc.; director of research at Harrisburg Family Practice Residency in Harrisburg, Pa.; and director of medical education, Pinnacle Health System, Harrisburg.

Jay Siwek, M.D., is editor of American Family Physician and professor and chair in the Department of Family Medicine at Georgetown University Medical Center, Washington, D.C.

Address correspondence to Allen F. Shaughnessy, Pharm.D., Harrisburg Family Practice Residency, 2501 N. Third St., Harrisburg, PA 17110 (e-mail: ashaughnessy@pinnaclehealth.org). Reprints are not available from the authors.

Promoting Physical Activity in the Family Practice Setting

See article on page 1249.

LORRAINE S. WALLACE, PH.D.,
EDWIN S. ROGERS, PH.D., and
KENNETH BIELAK, M.D., M.B.A.
University of Tennessee Graduate School of Medicine, Knoxville, Tennessee

It is a daily and unfortunate scene in the family physician's office: a succession of patients for whom the best prescription is a lifestyle modification. One such modification could be an increase in physical activity. The preventive health benefits of regular physical activity are well documented.¹ Not only would physical health improve,² but the psychologic health of most patients also would improve because of the positive effects on stress-related anxiety and depression.^3,4

The obesity rate for Americans is increasing. Recent large-scale studies⁵ have estimated that between one fourth and one half of American adults are obese. The American Dietetic Association considers physical activity a vital component of weight management.⁶ McInnis⁷ and colleagues discuss the promotion of physical activity for overweight and obese patients in this issue of American Family Physician.

Despite clear benefits to many aspects of patients' health, some family physicians are reluctant to advise patients to increase their physical activity.⁸ Although regular physical activity is associated with decreased incidence of coronary heart disease, osteoporosis, stroke, colon cancer, type 2 diabetes, and obesity, the majority of American adults are irregularly active or completely sedentary.^1,9 The Centers for Disease Control and Prevention and the American College of Sports Medicine¹ recommend that adults engage in moderate-intensity activity (e.g., walking 3 to 4 mph) for at least 30 minutes per day on most--preferably all--days of the week. Epidemiologic studies indicate that American adults, particularly women, are moving away from the Healthy People 2010 objective of increasing the proportion of adults who are meeting this recommendation.¹⁰ For example, less than 15 percent of American adults engage in moderate activity for at least 30 minutes per day.¹

The U.S. Preventive Services Task Force (USPSTF) reviewed eight fair- to good-quality trials relating to physical activity and found insufficient evidence to recommend for or against behavior counseling in primary care settings to promote physical activity.¹¹ However, multicomponent interventions that combine physician advice with behavior components, such as written exercise prescriptions, individual goal setting, follow-up via telephone, mail, or Internet, and individually tailored physical activity materials and regimens, appear promising. Linking patients with community-based physical activity programs also has been shown to increase the impact of physician counseling.¹²

Healthy People 2010 guidelines differ from the USPSTF recommendations by encouraging physicians to routinely counsel their patients to be physically active (Objective 1.3a).¹⁰ However, time constraints, limited access to allied health professionals (i.e., psychologists, registered dietitians, health educators), and limited training in prescribing exercise make promoting physical activity in the primary care setting a challenge.^13,14

Throughout the past decade, randomized controlled trials such as the Activity Counseling Trial (ACT)¹⁵ and Patient-Centered Assessment Counseling for Exercise and Nutrition (PACE)¹⁶ have been used with mixed success in the primary care setting. Based on the results of the ACT, PACE, and others, the family physician can implement cost- and time-effective physical activity strategies, including the following:

• Emphasizing the link between reduced disease risk and physical activity.
• Pointing out the role of physical activity in weight control.
• Providing a written prescription for exercise.
• Emphasizing that 30 minutes of daily physical activity can make a substantial difference in long-term health outcomes.
• Encouraging patients to select activities they enjoy.
• Encouraging patients to find someone with whom to exercise.
• Encouraging patients to keep a diary to monitor their behavior.

Increasing physical activity among American adults is necessary to reduce the morbidity and mortality associated with chronic disease. Family physicians, with their characteristic emphasis on long-term care in the context of long-term relationships, are ideal agents to deliver this message. Their efforts can be bolstered by more research into which interventions are effective for increasing their patients' levels of physical activity.

REFERENCES

1. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-7.
2. Johansson SE, Sundquist J. Change in lifestyle factors and their influence on health status and all-cause mortality. Int J Epidemiol 1999;28:1073-80.
3. King CN, Senn MD. Exercise testing and prescription. Practical recommendations for the sedentary. Sports Med 1996;21:326-36.
4. Paluska SA, Schwenk TL. Physical activity and mental health: current concepts. Sports Med 2000; 29:167-80.
5. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002;288:1723-7.
6. Cummings S, Parham ES, Strain GW. Position of the American Dietetic Association: weight management. J Am Diet Assoc 2002;102:1145-55.
7. McInnis KJ, Franklin BA, Rippe JM. Counseling for physical activity in overweight and obese patients. Am Fam Physician 2003;67:1249-56.
8. Glasgow RE, Eakin EG, Fisher EB, Bacak SJ, Brownson RC. Physician advice and support for physical activity: results from a national survey. Am J Prev Med 2001;21:189-96.
9. U.S. Public Health Service. Office of the Surgeon General. Physical activity and health: a report of the Surgeon General. Pittsburgh, Pa.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996.
10. Healthy People 2010. Accessed February 2003 at: www.healthypeople.gov.
11. U.S. Preventive Services Task Force. Behavioral counseling in primary care to promote physical activity. Recommendations and rationale. Accessed February 2003 at: www.ahrq.gov/clinic/3rduspstf/ physactivity/physactrr.htm.
12. Recommendations to increase physical activity in communities. Am J Prev Med 2002;22(suppl 4):67-72.
13. Connaughton AV, Weiler RM, Connaughton DP. Graduating medical students' exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010. Public Health Rep 2001;116:226-34.
14. Walsh JM, Swangard DM, Davis T, McPhee SJ. Exercise counseling by primary care physicians in the era of managed care. Am J Prev Med 1999; 16:307-13.
15. Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW 3d., Blair SN. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. JAMA 1999;281:327-34.
16. Calfas KJ, Sallis JF, Zabinski MF, Wilfley DE, Rupp J, Prochaska JJ, et al. Preliminary evaluation of a multicomponent program for nutrition and physical activity change in primary care: PACE+ for adults. Prev Med 2002;34:153-61.

Lorraine S. Wallace, Ph.D., and Edwin S. Rogers, Ph.D., are assistant professors of family medicine at the University of Tennessee Graduate School of Medicine, Knoxville. Dr. Wallace received her doctoral degree from Ohio State University, Columbus. Dr. Rogers received his doctoral degree from the University of Tennessee, Knoxville. Kenneth Bielak, M.D., M.B.A., is associate professor of family medicine at the University of Tennessee Graduate School of Medicine. He received his medical degree from Michigan State University College of Human Medicine, East Lansing, and completed a residency at Saginaw Cooperative Hospitals. He received his M.B.A. from the University of Tennessee, Knoxville, and completed a fellowship in sports medicine at the Hughston Clinic, Columbus, Ga.

Address correspondence to Lorraine S. Wallace, Ph.D., University of Tennessee Graduate School of Medicine, Department of Family Medicine, 1924 Alcoa Hwy., U-67, Knoxville, TN 37920 (e-mail: lwallace@mc.utmck.edu).