Top 20 Research Studies of 2016 for Primary Care Physicians


Am Fam Physician. 2017 May 1;95(9):572-579.

  The full text of the POEMs discussed in this article is available at A list of top POEMs from previous years is available at

  See related Editor's Note.

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.

This article summarizes the top 20 original research studies and four practice guidelines of 2016, based on regular literature surveillance and as selected by members of the Canadian Medical Association. The studies, known as POEMs (patient-oriented evidence that matters), were rated highly because of their relevance, validity, and potential to change practice. Key hypertension treatment findings include reduced mortality (a benefit not demonstrated in lower-risk persons or persons with diabetes mellitus) but also an increase in harms with a more aggressive blood pressure target in high-risk persons with hypertension and without diabetes. Additionally, one study found that cardiovascular events are rare in patients who meet the criteria for hypertensive urgency. Regarding respiratory conditions, the combination of fluticasone and salmeterol is preferred to fluticasone alone in patients with moderate to severe asthma; nasal irrigation but not steam inhalation is beneficial for patients with chronic sinus symptoms; and delayed prescriptions reduce antibiotic use in patients with symptoms of acute respiratory infection. Studies on musculoskeletal topics found that of the nonsteroidal anti-inflammatory drugs currently available, diclofenac is most likely to be effective for hip or knee osteoarthritis; the benefits of opioids in patients with chronic low back pain are limited and not clearly superior to nonsteroidal anti-inflammatory drugs; and hip radiography is not helpful for diagnosing osteoarthritis of the hip. Regarding diabetes and obesity, the Mediterranean diet is more effective than a low-fat diet for weight loss, and aggressive blood pressure targets are not recommended in patients with diabetes, especially older persons. Other recommendations include use of an oral syringe rather than a medicine cup to measure liquid medications for children, and abrupt smoking cessation preceded by two weeks of nicotine replacement via a patch, rather than a slow phasing out of tobacco use. Finally, although azithromycin has a slightly higher failure rate than doxycycline for the treatment of chlamydia, it still cured 97% of patients in a randomized trial.

Each year, thousands of studies are published that are potentially relevant to primary care physicians. To help physicians identify the most important new research, the POEMs (patient-oriented evidence that matters) criteria were developed. According to these criteria, the most important research—defined as research that, if true, has the greatest potential to change practice—should be relevant and valid (i.e., at low risk of bias), and report patient-oriented outcomes such as morbidity, mortality, or quality of life.1 Since 1994, a team of primary care clinicians with expertise in evidence-based practice has performed monthly surveillance of more than 110 English-language research journals.2 Although more than 20,000 studies were published in these journals during 2016, only 264 met the POEMs criteria for validity, relevance, use of patient-oriented outcomes, and practice change. Each POEM is summarized in a structured critical appraisal written by one of the six expert reviewers and peer reviewed by faculty and fellows of the University of Missouri Department of Family Medicine. Writing and disseminating the POEMs are supported by subscriptions, without industry support.

The Canadian Medical Association (CMA) sponsors a subscription to the Daily InfoPOEMs for their members. Each member has the option to receive the daily POEM by e-mail and rate it using a brief survey called the Information Assessment Method. This validated survey is a tool to document clinical relevance, cognitive impact, use of the information in practice, and expected health benefits for patients if the results of the POEM are applied.3 This article presents the 20 POEMs of 2016 that were most highly rated by CMA members for clinical relevance to one or more of their patients.

In the sixth installment of this annual series,48 we summarize the clinical question and bottom-line answer for each of the 20 top-rated POEMs. The POEMs have been organized by topic, and each is accompanied by a brief discussion. The bottom-line answers have been rewritten somewhat from the original to better stand alone without the complete synopsis. We also briefly discuss four POEMs that summarize highly relevant practice guidelines. The full POEMs are available online at


The first group of POEMs focuses on hypertension (Table 1).914 Study 1, the SPRINT (Systolic Blood Pressure Intervention Trial) study, reported a reduction in all-cause and cardiovascular (CV) mortality in older high-risk patients without diabetes mellitus who were randomized

The Authors

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MARK H. EBELL, MD, MS, is a professor in the Department of Epidemiology at the University of Georgia, 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, 125 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.

editor's note: This article was cowritten by Dr. Mark Ebell, who was a member of the U.S. Preventive Services Task Force (USPSTF) from 2012 to 2015 and currently serves as a consultant to the USPSTF. This article does not necessarily represent the views and policies of the USPSTF. Dr. Ebell is deputy editor for American Family Physician (AFP) and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. The POEMs described in this article stem from work that Dr. Ebell and his colleagues have been doing for the past two decades. Medical journals occasionally publish an article summarizing the best studies in a certain field from the previous year; however, those articles are limited by being one person's idiosyncratic collection of a handful of studies. In contrast, this article by Drs. Ebell and Roland Grad is validated in two ways: (1) the source material (POEMs) was derived from a systematic review of thousands of articles using a rigorous criterion-based process, and (2) these “best of the best” summaries were rated by thousands of Canadian primary care physicians for relevance and benefits to practice.

Because of Dr. Ebell's dual roles and ties to Essential Evidence Plus, the concept for this article was independently reviewed and approved by a group of AFP's medical editors. In addition, the article underwent peer review and editing by three of AFP's medical editors. Dr. Ebell was not involved in the editorial decision-making process.—Jay Siwek, MD, Editor, American Family Physician

The authors thank Wiley-Blackwell, Inc., for giving permission to excerpt the POEMs; Drs. Allen Shaughnessy, Henry Barry, David Slawson, Nita Kulkarni, and Linda Speer for their work in selecting and writing the original POEMs; the academic family medicine fellows and faculty of the University of Missouri–Columbia, for their work as peer reviewers; Pierre Pluye, PhD, for his work in codeveloping the Information Assessment Method; and Maria Vlasak for her assistance with copyediting the POEMs for the past 23 years.



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1. 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....

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

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 2015 for primary care physicians. Am Fam Physician. 2016;93(9):756–762.

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 2013 for primary care physicians. Am Fam Physician. 2014;90(6):397–402.

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

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

9. Wright JT Jr, Williamson JD, Whelton PK, et al.; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103–2116.

10. Lonn EM, Bosch J, López-Jaramillo P, et al.; HOPE-3 Investigators. Blood-pressure lowering in intermediate risk persons without cardiovascular disease. N Engl J Med. 2016;374(21):2009–2020.

11. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387(10017):435–443.

12. Yusuf S, Lonn E, Pais P, et al.; HOPE-3 Investigators. Blood-pressure and cholesterol lowering in persons without cardiovascular disease. N Engl J Med. 2016;374(21):2032–2043.

13. Williams B, MacDonald TM, Morant S, et al.; British Hypertension Society's PATHWAY Studies Group. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015;386(10008):2059–2068.

14. Patel KK, Young L, Howell EH, et al. Characteristics and outcomes of patients presenting with hypertensive urgency in the office setting. JAMA Intern Med. 2016;176(7):981–988.

15. Stempel DA, Raphiou IH, Kral KM, et al.; AUSTRI Investigators. Serious asthma events with fluticasone plus salmeterol versus fluticasone alone. N Engl J Med. 2016;374(19):1822–1830.

16. Little P, Stuart B, Mullee M, et al.; SNIFS Study Team. Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial. CMAJ. 2016;188(13):940–949.

17. de la Poza Abad M, Mas Dalmau G, Moreno Bakedano M, et al.; Delayed Antibiotic Prescription (DAP) Group. Prescription strategies in acute uncomplicated respiratory infections. a randomized clinical trial. JAMA Intern Med. 2016;176(1):21–29.

18. da Costa BR, Reichenbach S, Keller N, et al. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis. Lancet. 2016;387(10033):2093–2105.

19. Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(7):958–968.

20. Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ. 2015;351h5983.

21. Brunström M, Carlberg B. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses. BMJ. 2016;352i717.

22. Hamada S, Gulliford MC. Mortality in individuals aged 80 and older with type 2 diabetes mellitus in relation to glycosylated hemoglobin, blood pressure, and total cholesterol. J Am Geriatr Soc. 2016;64(7):1425–1431.

23. Mancini JG, Filion KB, Atallah R, Eisenberg MJ. Systematic review of the Mediterranean diet for long-term weight loss. Am J Med. 2016;129(4):407–415.e4.

24. Lindson-Hawley N, Banting M, West R, Michie S, Shinkins B, Aveyard P. Gradual versus abrupt smoking cessation. A randomized, controlled noninferiority trial. Ann Intern Med. 2016;164(9):585–592.

25. Narayana S, McGee S. Bedside diagnosis of the ‘red eye’: a systematic review. Am J Med. 2015;128(11):1220–1224.e1.

26. Geisler WM, Uniyal A, Lee JY, et al. Azithromycin versus doxycycline for urogenital Chlamydia trachomatis infection. N Engl J Med. 2015;373(26):2512–2521.

27. Weill A, Dalichampt M, Raguideau F, et al. Low dose oestrogen combined oral contraception and risk of pulmonary embolism, stroke, and myocardial infarction in five million French women: cohort study. BMJ. 2016;353i2002.

28. Yin HS, Parker RM, Sanders LM, et al. Liquid medication errors and dosing tools: a randomized controlled experiment. Pediatrics. 2016;138(4):e20160357.

29. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement [published correction appears in JAMA. 2016;316(5):545]. JAMA. 2016;315(23):2564–2575.

30. Siu AL. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163(8):622–634.

31. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125–133.

32. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–1645.

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



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