Top 20 Research Studies of 2014 for Primary Care Physicians


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.

FREE PREVIEW. Purchase online access to read the full version of this article.

Am Fam Physician. 2015 Sep 1;92(5):377-383.

  POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell, Inc. For more information, see

  The full text of the POEMs discussed in this article is available at

Author disclosure: Dr. Ebell is cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. Dr. Grad has no relevant financial affiliations. See Editor's Note.

A team of primary care clinicians with expertise in evidence-based medicine performed monthly surveillance of more than 110 English-language clinical research journals during 2014, and identified 255 studies that had the potential to change how family physicians practice. Each study was critically appraised and summarized, focusing on its relevance to primary care practice, validity, and likelihood that it could change practice. A validated tool was used to obtain feedback from members of the Canadian Medical Association about the clinical relevance of each POEM (patient-oriented evidence that matters) and the benefits they expect for their practice. This article, the fourth installment in this annual series, summarizes the 20 POEMs based on original research studies judged to have the greatest impact on practice for family physicians. Key studies for this year include advice on symptomatic management and prognosis for acute respiratory infections; a novel and effective strengthening treatment for plantar fasciitis; a study showing that varenicline plus nicotine replacement is more effective than varenicline alone; a network meta-analysis concluding that angiotensin-converting enzyme inhibitors are preferred over angiotensin II receptor blockers; the clear benefits of initial therapy with metformin over other agents in patients with diabetes mellitus; and important guidance on the use of anticoagulants.

For more than 20 years, a group of clinicians with expertise in primary care and evidence-based practice have performed monthly surveillance of more than 110 English-language research journals.1 Of more than 20,000 research studies published in these journals during 2014, 255 met our criteria for validity, relevance, and practice change. We considered a study to be valid if it avoided important biases such as failure to conceal allocation or failure to mask outcome assessment. Relevance is defined as a study that reports patient-oriented outcomes, such as morbidity, mortality, or quality of life. We also prioritize studies that would change practice over those that merely confirm existing practice (that is, they “matter”). Studies that meet these criteria are called POEMs, or patient-oriented evidence that matters.2

Since 2005, the Canadian Medical Association (CMA) has sponsored a subscription to POEMs for all of its members. Each member has the option to receive the daily POEM by e-mail. When members read the POEM, they can also rate it with a validated tool called the Information Assessment Method (IAM). The IAM tool addresses relevance to clinicians, cognitive impact, use in practice, and expected health benefits if the results of the POEM are applied.3 For this article, we identified the 20 POEMs that were rated highest for clinical relevance by CMA members for 2014. Each POEM was rated by at least 500 physicians. At least 70% of respondents rated each of these POEMs as “totally relevant for at least one of your patients,” whereas less than 15% rated each as “not relevant for at least one of your patients.”

In this fourth installment of this annual series,46 we summarize the clinical question and bottom-line answer for each POEM, organized by topic and followed by a brief discussion. The full POEMs are available online at

Respiratory Disease

View/Print Table

Table 1.

Respiratory Disease

Clinical questionBottom-line answer

1. In treating acute respiratory tract infections, is advice to use an analgesic “only as needed,” regular dosing of an analgesic, steam inhalation, or any combination effective in relieving symptoms?7

Advice regarding the use of steam inhalation, ibuprofen alone, acetaminophen alone, alternating ibuprofen with acetaminophen, and regular vs. as-needed use of analgesics did not show any improved effectiveness in treating symptoms of acute respiratory tract infections. Ibuprofen may be beneficial in patients with chest symptoms and in children. However, ibuprofen advice was associated with a slight increase in the number of patients seeking a second visit for the same illness.

2. Are delayed prescriptions for respiratory tract infections effective for decreasing antibiotic use?8

A delayed prescription approach in children and adults with acute respiratory tract infections, combined with explicit instructions for symptom control, is effective in decreasing antibiotic use, while not adversely affecting patient satisfaction or symptom duration or severity. Asking patients to call, pick up, or simply hold a prescription for a prescribed time resulted in less than 40% of patients receiving antibiotics.

3. For common respiratory tract infections in children, what is the best guidance we can give parents

The Authors

show all author info

MARK H. EBELL, MD, MS, is a professor of epidemiology in the College of Public Health at the University of Georgia in Athens....

ROLAND GRAD, MD, MSc, is an associate professor in the Department of Family Medicine at McGill University, Montreal, Quebec, Canada.

Address correspondence to Mark H. Ebell, MD, MS, University of Georgia, 233 Miller Hall, UGA Health Sciences Campus, Athens, GA 30602 (e-mail: Reprints are not available from the authors.

Author disclosure: Dr. Ebell is cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. Dr. Grad has no relevant financial affiliations. See Editor's Note.


show all references

1. Ebell MH, Barry HC, Slawson DC, Shaughnessy AF. Finding POEMs in the medical literature. J Fam Pract. 1999;48(5):350–355....

2. Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract. 1994;39(5):489–499.

3. Pluye P, Grad RM, Johnson-Lafleur J, et al. Evaluation of email alerts in practice: Part 2. Validation of the information assessment method. J Eval Clin Pract. 2010;16(6):1236–1243.

4. Ebell MH, Grad R. Top 20 research studies of 2013 for primary care physicians. Am Fam Physician. 2014;90(6):397–402.

5. Ebell MH, Grad R. Top 20 research studies of 2012 for primary care physicians. Am Fam Physician. 2013;88(6):380–386.

6. Ebell MH, Grad R. Top 20 research studies of 2011 for primary care physicians. Am Fam Physician. 2012;86(9):835–840.

7. Little P, Moore M, Kelly J, et al.; PIPS Investigators. Ibuprofen, paracetamol, and steam for patients with respiratory tract infections in primary care: pragmatic randomised factorial trial. BMJ. 2013;347:f6041.

8. Little P, Moore M, Kelly J, et al.; PIPS Investigators. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, randomised controlled trial. BMJ. 2014;348:g1606.

9. Thompson M, Vodicka TA, Blair PS, Buckley DI, Heneghan C, Hay AD; TARGET Programme Team. Duration of symptoms of respiratory tract infections in children: systematic review [published correction appears in BMJ. 2014;347:f7575]. BMJ. 2013;347:f7027.

10. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2015;25(3):e292–e300.

11. Rhon DI, Boyles RB, Cleland JA. One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: a pragmatic randomized trial. Ann Intern Med. 2014;161(3):161–169.

12. Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC. Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review. Spine (Phila Pa 1976). 2014;39(7):556–563.

13. Bazzano LA, Hu T, Reynolds K, et al. Effects of low-carbohydrate and low-fat diets: a randomized trial. Ann Intern Med. 2014;161(5):309–318.

14. Koegelenberg CF, Noor F, Bateman ED, et al. Efficacy of varenicline combined with nicotine replacement therapy vs varenicline alone for smoking cessation: a randomized clinical trial. JAMA. 2014;312(2):155–161.

15. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change in mental health after smoking cessation: systematic review and meta-analysis [published correction appears in BMJ. 2014;348:g2216]. BMJ. 2014;348:g1151.

16. Patel A, MacMahon S, Chalmers J, et al.; ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358(24):2560–2572.

17. Zoungas S, Chalmers J, Neal B, et al.; ADVANCE-ON Collaborative Group. Follow-up of blood-pressure lowering and glucose control in type 2 diabetes. N Engl J Med. 2014;371(15):1392–1406.

18. Cheng J, Zhang W, Zhang X, et al. Effect of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on all-cause mortality, cardiovascular deaths, and cardiovascular events in patients with diabetes mellitus: a meta-analysis. JAMA Intern Med. 2014; 174(5):773–785.

19. Berkowitz SA, Krumme AA, Avorn J, et al. Initial choice of oral glucose-lowering medication for diabetes mellitus: a patient-centered comparative effectiveness study. JAMA Intern Med. 2014;174(12):1955–1962.

20. Sundström J, Arima H, Woodward M, et al.; Blood Pressure Lowering Treatment Trialists' Collaboration. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;384(9943):591–598.

21. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955–962.

22. Steinberg BA, Kim S, Piccini JP, et al. Use and associated risks of concomitant aspirin therapy with oral anticoagulation in patients with atrial fibrillation: insights from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) Registry. Circulation. 2013;128(7):721–728.

23. Davidson BL, Verheijen S, Lensing AW, et al. Bleeding risk of patients with acute venous thromboembolism taking nonsteroidal anti-inflammatory drugs or aspirin. JAMA Intern Med. 2014;174(6):947–953.

24. Keene D, Price C, Shun-Shin MJ, Francis DP. Effect on cardiovascular risk of high density lipoprotein targeted drug treatments niacin, fibrates, and CETP inhibitors: meta-analysis of randomised controlled trials including 117,411 patients. BMJ. 2014;349:g4379.

25. Lee JK, Liles EG, Bent S, Levin TR, Corley DA. Accuracy of fecal immunochemical tests for colorectal cancer: systematic review and meta-analysis. Ann Intern Med. 2014;160(3):171–181.

26. Pecina J, Garrison GM, Bernard ME. Levothyroxine dosage is associated with stability of thyroid-stimulating hormone values. Am J Med. 2014;127(3):240–245.

27. Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med. 2013;369(20):1883–1891.

28. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) [published correction appears in JAMA. 2014;311(17):1809]. JAMA. 2014;311(5):507–520.

29. Bloomfield HE, Olson A, Greer N, et al. Screening pelvic examinations in asymptomatic, average-risk adult women: an evidence report for a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(1):46–53.

30. Ebell MH, Culp M, Lastinger K, Dasigi T. A systematic review of the bimanual examination as a test for ovarian cancer. Am J Prev Med. 2015;48(3):350–356.

31. Welch HG, Passow HJ. Quantifying the benefits and harms of screening mammography. JAMA Intern Med. 2014;174(3):448–454.


Copyright © 2015 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in Pubmed


Sep 15, 2016

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article