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 https://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
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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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