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.
Additional Top POEMs from 2017 Consistent with the Principles of the Choosing Wisely Campaign
|Clinical question||Bottom-line answer||Clinical 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
Referencesshow all references
1. Morgan DJ, Dhruva SS, Coon ER, Wright SM, Korenstein D. 2017 Update on medical overuse: a systematic review. JAMA Intern Med. 2018;178(1):110–115....
2. 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.
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.
8. Drieling RL, LaCroix AZ, Beresford SA, et al. Long-term oral bisphosphonate therapy and fractures in older women: the Women's Health Initiative. J Am Geriatr Soc. 2017;65(9):1924–1931.
9. Roman-Blas JA, Castañeda S, Sánchez-Pernaute O, Largo R, Herrero-Beaumont G; CS/GS Combined Therapy Study Group. Combined treatment with chondroitin sulfate and glucosamine sulfate shows no superiority over placebo for reduction of joint pain and functional impairment in patients with knee osteoarthritis: a six-month multicenter, randomized, double-blind, placebo-controlled clinical trial [published correction appears in Arthritis Rheumatol. 2017;69(10):2080]. Arthritis Rheumatol. 2017;69(1):77–85.
10. Friedman BW, Irizarry E, Solorzano C, et al. Diazepam is no better than placebo when added to naproxen for acute low back pain. Ann Emerg Med. 2017;70(2):169–176.e1.
11. Stahel PF, Wang P, Hutfless S, et al. Surgeon practice patterns of arthroscopic partial meniscectomy for degenerative disease in the United States: a measure of low-value care. JAMA Surg. 2018;153(5):494–496.
12. Qaseem A, Forciea MA, McLean RM, Denberg TD. Treatment of low bone density or osteoporosis to prevent fractures in men and women: a clinical practice guideline update from the American College of Physicians [published correction appears in Ann Intern Med. 2017;167(6): 448]. Ann Intern Med. 2017;166(11):818–839.
13. American Academy of Family Physicians. Clinical practice guideline. Treatment of low bone density or osteoporosis. https://www.aafp.org/news/health-of-the-public/20170511acposteoguide.html. Accessed June 2, 2018.
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.
15. Aaron SD, Vandemheen KL, FitzGerald JM, et al.; Canadian Respiratory Research Network. Reevaluation of diagnosis in adults with physician-diagnosed asthma. JAMA. 2017;317(3):269–279.
16. Aberle DR, Adams AM, Berg CD; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomo-graphic screening. N Engl J Med. 2011;365(5):395–409.
17. Canadian Task Force on Preventive Health Care. Lung cancer. 2016. https://canadiantaskforce.ca/guidelines/published-guidelines/lung-cancer/. Accessed June 2, 2018.
18. U.S. Preventive Services Task Force. Lung cancer: screening. December 2013. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening. Accessed June 2, 2018.
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.
27. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published corrections appear in J Am Coll Cardiol. 2015;66(24):2812 and J Am Coll Cardiol. 2014;63(25 pt B):3024–3025]. J Am Coll Cardiol. 2014;63(25 pt B):2889–2934.
28. U.S. Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease in adults: preventive medication. November 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/statin-use-in-adults-preventive-medication1. Accessed June 2, 2018.
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.
Copyright © 2018 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