Top POEMs of 2016 Consistent with the Principles of the Choosing Wisely Campaign
Am Fam Physician. 2017 Aug 15;96(4):234-239.
The full text of the POEMs discussed in this article is available at http://www.aafp.org/afp/poems-cw-2016.
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.
A challenge in the Choosing Wisely campaign is to identify low-value clinical actions supported by high-quality evidence. We applied a method based on crowdsourcing the Daily POEM (patient-oriented evidence that matters) to identify low-value clinical actions from research studies consistent with the principles of Choosing Wisely. In 2016, we analyzed an average of 1,382 questionnaires on 265 unique POEMs delivered to physician members of the Canadian Medical Association. From these questionnaires, we identified the POEMs ranking highest on one questionnaire item directly linked to reducing overdiagnosis or overtreatment. The recommendations from these POEMs based on primary research or meta-analyses are presented as actions to consider avoiding in clinical practice. These recommendations fall into the categories of musculoskeletal conditions (e.g., degenerative meniscal tears, chronic low back pain), cardiovascular disease (e.g., chronic stable angina, heart failure with preserved ejection fraction), respiratory disease (e.g., pneumonia, asthma exacerbations), and preventive care (e.g., screening for lung, colorectal, or ovarian cancer). Based on the results of the studies, these recommendations describe interventions whose benefits are not superior to other options, are sometimes more expensive, or put patients at increased risk of harm. Knowing more about these POEMs and their connection with the Choosing Wisely campaign will help clinicians and their patients engage in conversations better informed by high-quality evidence.
The Choosing Wisely campaign challenges physicians to identify so-called low-value clinical actions supported by high-quality evidence. This article reviews the Daily POEMs (patient-oriented evidence that matters) from recent research that are most consistent with principles of the campaign. However, unlike the actual Choosing Wisely recommendations,1 all recommendations derived from POEMs are based on empirical data from clinical research involving patient-oriented outcomes.2 In addition, because POEMs are selected through a crowdsourcing method, the POEMs in this article were chosen not by experts but by thousands of physicians in a continuing medical education program sponsored by the Canadian Medical Association.3
The selection method is based on big data obtained by linking the daily POEM to a brief validated questionnaire.4,5 In 2016, an average of 1,382 questionnaires on 265 unique POEMs were analyzed to identify the studies ranking highest on one questionnaire item: “This information will help to avoid unnecessary treatment, diagnostic procedures, preventive interventions, or a referral for this patient.” This item was chosen because of its direct link to the Choosing Wisely campaign. To maintain a focus on research studies, POEMs about guidelines were excluded. We also excluded nine of the most relevant POEMs of 2016 that were discussed earlier this year in American Family Physician.6 However, to highlight their importance for clinical practice, these POEMs are available online (eTable A).
Additional Top POEMs from 2016 Consistent with the Principles of the Choosing Wisely Campaign
|Clinical question||Bottom-line answer||Clinical actions to consider for Choosing Wisely|
Is there an association between mortality and glycemic control, blood pressure levels, and cholesterol levels in patients with type 2 diabetes mellitus who are older than 80 years?A1
Although subject to many of the limitations of cohort studies, the data from this study are consistent with those from many other studies that suggest that older patients are worse off with low A1C, low blood pressure, and low cholesterol levels.
In patients older than 80 years, do not routinely intensify treatment to achieve lower target values of systolic blood pressure, A1C, and total cholesterol.
In patients with an intermediate risk of CV disease, does blood pressure lowering (regardless of initial blood pressure) improve clinical outcomes?A2
This large randomized trial provides important guidance for primary care physicians and their patients. For patients at intermediate risk of CV disease who have a systolic blood pressure lower than 143 mm Hg, there is no benefit to prescribing candesartan/hydrochlorothiazide (Atacand HCT). For those with elevated blood pressure, there is a small benefit in terms of the composite outcome (number needed to treat = 59 over 5.6 years to prevent one CV death, nonfatal myocardial infarction, or nonfatal stroke) but no all-cause mortality benefit. The recent SPRINT (Systolic Blood Pressure Intervention Trial) trial found a benefit but in a much higher-risk group. This study supports current recommendations for limiting use of antihypertensives in low-risk and intermediate-risk patients to those with a systolic blood pressure higher than 140 mm Hg.
In patients at intermediate risk of CV
editor's note: This article was cowritten by Dr. Mark Ebell, Deputy Editor for AFP and cofounder and Editor-in-Chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. Because of Dr. Ebell's dual roles and ties to Essential Evidence Plus, 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
REFERENCESshow all references
1. Lin KW, Yancey JR. Evaluating the evidence for Choosing Wisely in primary care using the Strength of Recommendation Taxonomy (SORT). J Am Board Fam Med. 2016;29(4):512–515....
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. 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.
4. 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.
5. Badran H, Pluye P, Grad R. When educational material is delivered: a mixed methods content validation study of the information assessment method. JMIR Med Educ. 2017;3(1):e4.
6. Ebell MH, Grad R. Top 20 research studies of 2016 for primary care physicians. Am Fam Physician. 2017;95(9):572–579.
7. Sihvonen R, Englund M, Turkiewicz A, Järvinen TL; Finnish Degenerative Meniscal Lesion Study Group. Mechanical symptoms and arthroscopic partial meniscectomy in patients with degenerative meniscus tear: a secondary analysis of a randomized trial. Ann Intern Med. 2016;164(7): 449–455.
8. Jevsevar D, Donnelly P, Brown GA, Cummins DS. Viscosupplementation for osteoarthritis of the knee: a systematic review of the evidence. J Bone Joint Surg Am. 2015;97(24):2047–2060.
9. Hinman RS, Wrigley TV, Metcalf BR, et al. Unloading shoes for self-management of knee osteoarthritis: a randomized trial. Ann Intern Med. 2016;165(6):381–389.
10. Hedlund R, Johansson C, Hägg O, Fritzell P, Tullberg T; Swedish Lumbar Spine Study Group. The long-term outcome of lumbar fusion in the Swedish lumbar spine study. Spine J. 2016;16(5):579–587.
11. Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415–2423.
12. Grad R, Ebell MH. Top POEMs of 2015 consistent with the principles of the Choosing Wisely campaign. Am Fam Physician. 2016;94(7):566–570.
13. Summaries for patients. Mechanical symptoms and arthroscopic partial meniscectomy in patients with degerenative meniscus tear. Ann Intern Med. 2016;164(7):I–15.
14. 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.
15. 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.
16. Försth P, Ólafsson G, Carlsson T, et al. A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med. 2016;374(15): 1413–1423.
17. Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572–1580.
18. Sedlis SP, Hartigan PM, Teo KK, et al.; COURAGE Trial Investigators. Effect of PCI on long-term survival in patients with stable ischemic heart disease. N Engl J Med. 2015;373(20):1937–1946.
19. U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA review finds long-term treatment with blood-thinning medicine Plavix (clopidogrel) does not change risk of death. November 6, 2015. https://www.fda.gov/drugs/drugsafety/ucm471286.htm. Accessed June 27, 2017.
20. Redfield MM, Anstrom KJ, Levine JA, et al.; NHLBI Heart Failure Clinical Research Network. Isosorbide mononitrate in heart failure with preserved ejection fraction. N Engl J Med. 2015;373(24):2314–2324.
21. Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016;176(9):1257–1265.
22. Johnston SL, Szigeti M, Cross M, et al. Azithromycin for acute exacerbations of asthma: the AZALEA randomized clinical trial. JAMA Intern Med. 2016;176(11):1630–1637.
23. Hamelmann E, Bateman ED, Vogelberg C, et al. Tiotropium add-on therapy in adolescents with moderate asthma: a 1-year randomized controlled trial. J Allergy Clin Immunol. 2016;138(2):441–450.e8.
24. Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma [published correction appears in Eur Respir J. 2014;43(4):1216]. Eur Respir J. 2014; 43(2):343–373.
25. Kerstjens HA, Engel M, Dahl R, et al. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med. 2012;367(13): 1198–1207.
26. Hoffmann TC, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274–286.
27. Jacobs IJ, Menon U, Ryan A, et al. Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKC-TOCS): a randomised controlled trial [published correction appears in Lancet. 2016;387(10022):944]. Lancet. 2016;387(10022):945–956.
28. Usman Ali M, Miller J, Peirson L, et al. Screening for lung cancer: a systematic review and meta-analysis. Prev Med. 2016;89:301–314.
29. Schoen RE, Razzak A, Yu KJ, et al. Incidence and mortality of colorectal cancer in individuals with a family history of colorectal cancer. Gastroenterology. 2015;149(6):1438–1445.e1.
30. Rana JS, Tabada GH, Solomon MD, et al. Accuracy of the atherosclerotic cardiovascular risk equation in a large contemporary, multiethnic population. J Am Coll Cardiol. 2016;67(18):2118–2130.
31. Juthani-Mehta M, Van Ness PH, Bianco L, et al. Effect of cranberry capsules on bacteriuria plus pyuria among older women in nursing homes: a randomized clinical trial. JAMA. 2016;316(18):1879–1887.
32. Moyer VA. Screening for ovarian cancer: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2012; 157(12):900–940.
33. Black WC, Gareen IF, Soneji SS, et al. Cost-effectiveness of CT screening in the National Lung Screening Trial. N Engl J Med. 2014;371(19): 1793–1802.
34. D'Agostino RB Sr., Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008;117(6):743–753.
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.
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