Top POEMs of 2017 Consistent with the Principles of the Choosing Wisely Campaign

 

Am Fam Physician. 2018 Jul 15;98(2):93-98.

The full text of the POEMs discussed in this article is available at https://www.aafp.org/afp/poems-cw-2017.

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.

This article discusses the POEMs (patient-oriented evidence that matters) of 2017 judged to be most consistent with the principles of the Choosing Wisely campaign. A POEM is a synopsis of a research study that reports patient-oriented outcomes, such as improvement in symptoms, quality of life, or mortality; is free of important methodologic bias; and recommends a change in practice for many physicians. We selected these POEMs through a crowdsourcing strategy of the daily POEMs information service for physician-members of the Canadian Medical Association. Recommendations are presented from these top POEMs of primary research or meta-analysis as interventions to consider avoiding in practice. The recommendations cover musculoskeletal conditions (e.g., avoid arthroscopy for initial treatment of a meniscal tear), respiratory disease (e.g., avoid screening for lung cancer without informing your patient of the risk of a false-positive test result), infections (e.g., do not routinely add trimethoprim/sulfamethoxazole to cephalexin for nonpurulent uncomplicated cellulitis), and cardiovascular disease (e.g., do not prescribe niacin, alone or in combination with a statin, to prevent cardiovascular disease). These POEMs 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 that are better informed by high-quality evidence.

A POEM (patient-oriented evidence that matters) is a synopsis of a research study that reports patient-oriented outcomes, such as improvement in symptoms, quality of life, or mortality; is free of important methodologic bias; and recommends a change in practice for many physicians. In a popular continuing medical education program, physician members of the Canadian Medical Association receive the daily POEM and rate each one using a brief validated questionnaire. From these ratings, each year we select the daily POEMs that are most consistent with the principles of the Choosing Wisely campaign, an international effort to reduce unnecessary medical tests, treatments, and procedures. Unlike articles where experts choose the top research papers of the year,1 this crowdsourcing method allows us to identify new research studies about clinical actions most consistent with Choosing Wisely, from the perspective of physicians in everyday practice.2

This is the third installment of an annual series3,4 summarizing the actions to consider avoiding in clinical practice as identified from the POEMs rated in 2017. These data provided an average of 1,532 ratings on each of the 247 unique POEMs of the year.

From the data, we identified the top POEMs of primary research or meta-analysis where physicians said that study findings would help them to reduce overdiagnosis or over-treatment in clinical practice. We excluded 13 of the most relevant POEMs of 2017 because they were previously discussed in American Family Physician.5  However, to highlight their importance, these POEMs are available online (eTable A). Below, we organize the top POEMs for Choosing Wisely by condition and accompany each one with a brief discussion. We also discuss implications for decision making based on one of the most relevant clinical practice guidelines of 2017.

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eTABLE A

Additional Top POEMs from 2017 Consistent with the Principles of the Choosing Wisely Campaign

Clinical questionBottom-line answerClinical actions to consider for Choosing Wisely

Is confirmatory diagnostic testing cost-effective for the management of clinically suspected onychomycosis?A1

The most cost-effective approach to a patient with clinically suspected onychomycosis is empiric therapy with oral terbinafine (Lamisil). The chance of liver injury is estimated to be only one in 50,000 to one in 120,000, so testing to confirm the diagnosis would cost tens of millions of dollars per case of liver injury avoided. If you plan to prescribe the less effective and much more expensive topical solution efinaconazole (Jublia), then confirmatory testing with periodic acid-Schiff stain reduces costs.

If you are going to prescribe oral terbinafine, consider empiric therapy without confirmatory testing because it may be just as safe and is more cost-effective.

Is pregabalin (Lyrica) an effective treatment for the pain of acute or chronic sciatica?A2

Pregabalin does not relieve pain in patients with sciatica. This study randomized 207 patients with moderate to severe sciatica, and followed them for one year. The authors concluded that pregabalin does not relieve pain, improve function, or improve any other outcomes in patients with sciatica.

In patients with sciatica, do not routinely prescribe gabapentinoids such as pregabalin.

Do intra-articular cortic

The Authors

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

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

Address correspondence to Roland Grad, MD, MSc, McGill University, 3755 Cote Sainte Catherine Rd., Montreal, Quebec, Canada H3T 1E2 (e-mail: roland.grad@mcgill.ca). Reprints are not available from the authors.

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.

References

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3. 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.

4. Grad R, Ebell MH. Top POEMs of 2016 consistent with the principles of the Choosing Wisely campaign. Am Fam Physician. 2017;96(4):234–239.

5. Ebell MH, Grad R. Top 20 research studies of 2017 for primary care physicians. Am Fam Physician. 2018;97(9):581–588.

6. Monk P, Garfjeld Roberts P, Palmer AJ, et al. The urgent need for evidence in arthroscopic meniscal surgery. Am J Sports Med. 2017;45(4):965–973.

7. Kvalvaag E, Brox JI, Engebretsen KB, et al. Effectiveness of radial extra-corporeal shock wave therapy (rESWT) when combined with supervised exercises in patients with subacromial shoulder pain: a double-masked, randomized, sham-controlled trial. Am J Sports Med. 2017;45(11):2547–2554.

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14. Kinsinger LS, Anderson C, Kim J, et al. Implementation of lung cancer screening in the Veterans Health Administration. JAMA Intern Med. 2017;177(3):399–406.

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19. American Academy of Family Physicians. Clinical preventive service recommendation. Lung cancer. https://www.aafp.org/patient-care/clinical-recommendations/all/lung-cancer.html. Accessed June 2, 2018.

20. Grad R, Légaré F, Bell NR, et al. Shared decision making in preventive health care: what it is; what it is not. Can Fam Physician. 2017;63(9):682–684.

21. Hay AD, Little P, Harnden A, et al. Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: a randomized clinical trial. JAMA. 2017;318(8):721–730.

22. Steele DW, Adam GP, Di M, Halladay CH, Balk EM, Trikalinos TA. Effectiveness of tympanostomy tubes for otitis media: a meta-analysis. Pediatrics. 2017;139(6):e20170125.

23. Moran GJ, Krishnadasan A, Mower WR, et al. Effect of cephalexin plus trimethoprim-sulfamethoxazole vs cephalexin alone on clinical cure of uncomplicated cellulitis: a randomized clinical trial. JAMA. 2017;317(20):2088–2096.

24. Garg A, Sharma A, Krishnamoorthy P, et al. Role of niacin in current clinical practice: a systematic review. Am J Med. 2017;130(2):173–187.

25. Han BH, Sutin D, Williamson JD, et al. Effect of statin treatment vs usual care on primary cardiovascular prevention among older adults: The ALLHAT-LLT Randomized Clinical Trial. JAMA Intern Med. 2017;177(7):955–965.

26. 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.

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29. 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.

30. Barniol C, Dehours E, Mallet J, Houze-Cerfon CH, Lauque D, Charpentier S. Levocetirizine and prednisone are not superior to levocetirizine alone for the treatment of acute urticaria: a randomized double-blind clinical trial. Ann Emerg Med. 2018;71(1):125–131.e1.

31. Kaufman J, Fitzpatrick P, Tosif S, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ. 2017;357:j1341.

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

 

 

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