Am Fam Physician. 2016 Oct 1;94(7):566-570.
Related editorial: Of Wise Choices, Evidence That Matters, and Leaving Old Friends Behind
Author disclosure: Dr. Grad has no relevant financial affiliations. Dr. Ebell is cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. See Editor's Note.
The authors applied a novel method to identify recent clinical studies that showed results consistent with the principles of the Choosing Wisely campaign. The method, based on crowdsourcing studies known as POEMs (patient-oriented evidence that matters), involved analyzing POEM ratings submitted by physician members of the Canadian Medical Association in the context of their continuing medical education. In the 251 unique POEMs delivered to these physicians in 2015, an average of 1,284 physician ratings were received per POEM. The authors then identified the POEMs that ranked highest on a single item in the rating questionnaire—namely, whether the POEM helps reduce overdiagnosis or overtreatment, which is the focus of the Choosing Wisely campaign. The result is a set of POEMs of original research that describe interventions that are not superior to other options, are sometimes more expensive, or place patients at increased risk of harm. Knowing the bottom line of these studies could help physicians and patients engage in better conversations when making decisions about clinical care.
Choosing Wisely is an initiative that asks medical specialty societies to identify at least five things their members should no longer do because they represent low-value patient care.1 This article highlights the top research studies from 2015 that are consistent with this philosophy.
An annual series in American Family Physician summarizes the top original research studies of the year for primary care.2–6 The studies are selected for their relevance to practice and assessed for validity by independent experts in primary care and research methodology. Approximately 250 articles meet these criteria each year, and they are evaluated in the POEMs continuing medical education (CME) program in Canada.7 The top research studies are then identified based on ratings of clinical relevance submitted by Canadian physicians. POEMs stands for patient-oriented evidence that matters,8 which relates to changes in a patient's morbidity, mortality, or quality of life. It differs from disease-oriented evidence, which relates to changes in physiologic or surrogate markers of health, such as blood pressure, serum creatinine level, hemoglobin level, or neurotransmitters. These markers may or may not directly affect a patient's morbidity, mortality, or quality of life.
A 2015 article described how data from the same POEMs CME program could help the Choosing Wisely campaign systematically identify new recommendations for consideration by expert panels from specialty societies.9 For this article, a novel method of crowdsourcing was used to identify the most primary care–relevant studies of 2015 consistent with the principles of Choosing Wisely. This involved analyzing ratings of POEMs submitted by thousands of physician members of the Canadian Medical Association, using a validated questionnaire.10 For 251 unique POEMs delivered during the calendar year of 2015, an average of 1,284 physician ratings per POEM were received. The POEMs that ranked highest on one item in the rating questionnaire, namely “this information will help to avoid unnecessary treatment, diagnostic procedures, preventive interventions, or a referral for this patient,” were identified. This questionnaire item was chosen because of its direct link to the objective of the Choosing Wisely campaign: reducing overdiagnosis or overtreatment.
The POEMs in this article identify opportunities for physicians to engage in conversation with their patients about low-value care in a way that is consistent with the principles of Choosing Wisely. Many of these POEMs describe interventions that are not superior to other options, are sometimes more expensive, or place patients at increased risk of harm. To maintain a focus on research studies, POEMs about guidelines, such as those produced by the U.S. Preventive Services Task Force, were excluded. We also excluded 12 of the most relevant POEMs of 2015 that were discussed in a previous article.6 However, to highlight their relevance to the Choosing Wisely philosophy, these 12 POEMs are available online (eTable A).
Additional Top POEMs from 2015 Consistent with the Principles of the Choosing Wisely Campaign
|Clinical question||Bottom-line answer||Clinical actions to consider for Choosing Wisely|
Does early imaging of older adults with back pain improve outcomes?A1
Among adults 65 years or older who present to primary care clinicians for a new episode of back pain, imaging before six weeks resulted in no improved outcomes at one year, but increased overall health care costs by almost 30%.
In older patients with new onset back pain, do not routinely order early imaging.
Is acetaminophen effective for the treatment of low back pain or osteoarthritis?A2
Although acetaminophen was hoped to be a safer alternative to nonsteroidal anti-inflammatory drugs and opioids for the treatment of common musculoskeletal problems, on average it provides
REFERENCESshow all references
1. Choosing Wisely. http://www.choosingwisely.org. Accessed August 4, 2016....
2. Ebell MH, Grad R. Top 20 research studies of 2011 for primary care physicians. Am Fam Physician. 2012;86(9):835–840.
3. Ebell MH, Grad R. Top 20 research studies of 2012 for primary care physicians. Am Fam Physician. 2013;88(6):380–386.
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 2014 for primary care physicians. Am Fam Physician. 2015;92(5):377–383.
6. Ebell MH, Grad R. Top 20 research studies of 2015 for primary care physicians. Am Fam Physician. 2016;93(9):756–762.
7. Grad RM, Pluye P, Mercer J, et al. Impact of research-based synopses delivered as daily e-mail: a prospective observational study. J Am Med Inform Assoc. 2008;15(2):240–245.
8. 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.
9. Grad R, Pluye P, Tang D, Shulha M, Slawson DC, Shaughnessy AF. Patient-oriented evidence that matters (POEMs)™ suggest potential clinical topics for the Choosing Wisely™ campaign. J Am Board Fam Med. 2015;28(2):184–189.
10. 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.
11. Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ. 2015;350:h2747.
12. Khan M, Evaniew N, Bedi A, Ayeni OR, Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ. 2014;186(14):1057–1064.
13. Markman JD, Frazer ME, Rast SA, et al. Double-blind, randomized, controlled, crossover trial of pregabalin for neurogenic claudication. Neurology. 2015;84(3):265–272.
14. Cohen SP, Hanling S, Bicket MC, et al. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multi-center randomized double blind comparative efficacy study. BMJ. 2015;350:h1748.
15. Delitto A, Piva SR, Moore CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Ann Intern Med. 2015;162(7):465–473.
16. Filardo G, Di Matteo B, Di Martino A, et al. Platelet-rich plasma intra-articular knee injections show no superiority versus viscosupplementation: a randomized controlled trial. Am J Sports Med. 2015;43(7):1575–1582.
17. Henriksen M, Christensen R, Klokker L, et al. Evaluation of the benefit of corticosteroid injection before exercise therapy in patients with osteoarthritis of the knee: a randomized clinical trial. JAMA Intern Med. 2015;175(6):923–930.
18. Palacio LE. Osteoarthritis. Updated February 19, 2015. https://www.essentialevidenceplus.com/content/eee/703 [subscription required]. Accessed August 4, 2016.
19. Bangalore S, Makani H, Radford M, et al. Clinical outcomes with β-blockers for myocardial infarction: a meta-analysis of randomized trials. Am J Med. 2014;127(10):939–953.
20. Collet JP, Silvain J, Barthélémy O, et al.; ARCTIC investigators. Dual-antiplatelet treatment beyond 1 year after drug-eluting stent implantation (ARCTIC-Interruption): a randomised trial. Lancet. 2014;384(9954):1577–1585.
21. Muhlestein JB, Lappé DL, Lima JA, et al. Effect of screening for coronary artery disease using CT angiography on mortality and cardiac events in high-risk patients with diabetes: the FACTOR-64 randomized clinical trial. JAMA. 2014;312(21):2234–2243.
22. Green JB, Bethel MA, Armstrong PW, et al.; TECOS Study Group. Effect of sitagliptin on cardiovascular outcomes in type 2 diabetes [published correction appears in N Engl J Med. 2015;373(6):586]. N Engl J Med. 2015;373(3):232–242.
23. Clark NP, Witt DM, Davies LE, et al. Bleeding, recurrent venous thromboembolism, and mortality risks during warfarin interruption for invasive procedures. JAMA Intern Med. 2015;175(7):1163–1168.
24. Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 2015;131(5):488–494.
25. Douketis JD, Spyropoulos AC, Kaatz S, et al.; BRIDGE Investigators. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823–833.
26. Carrier M, Lazo-Langner A, Shivakumar S, et al.; SOME Investigators. Screening for occult cancer in unprovoked venous thromboembolism. N Engl J Med. 2015;373(8):697–704.
27. Hansen KE, Johnson RE, Chambers KR, et al. Treatment of vitamin D insufficiency in postmenopausal women: a randomized clinical trial. JAMA Intern Med. 2015;175(10):1612–1621.
POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell, Inc. For more information, see http://www.essentialevidenceplus.com.
The full text of the POEMs discussed in this article is available at http://www.aafp.org/afp/poems-cw-2015.
Copyright © 2016 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 firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions