Top 20 Research Studies of 2018 for Primary Care Physicians
Am Fam Physician. 2019 May 1;99(9):565-573.
The full text of the POEMs discussed in this article is available at https://www.aafp.org/afp/poems2018. A list of top POEMs from previous years is available at https://www.aafp.org/journals/afp/authors/ebm-toolkit/resources/top-poems.html.
Author disclosure: No relevant financial affiliations.
In 2018, through regular surveillance of more than 110 English-language research journals, 255 research studies met the criteria to become POEMs (patient-oriented evidence that matters). Using a validated tool, physician members of the Canadian Medical Association rated these POEMs for their relevance to patients in their practices. This article summarizes the clinical questions and bottom-line answers from the top 20 POEMs of 2018, as determined by these physicians. The top POEMs summarize potentially practice-changing research on the importance of accurate blood pressure measurement, the unclear benefits of lower blood pressure targets for hypertension, the lack of evidence regarding treatment of cough, advantages of shorter over longer courses of antibiotics for several common infections, the value of increased fluid intake for preventing recurrent urinary tract infections, and the benefit of nitrofurantoin over fosfomycin for the treatment of urinary tract infection. Other conclusions include the lack of benefit of anticonvulsants for low back pain, the value of nonopioid pain management compared with opioids, the risk of anxiety recurrence when an antidepressant is discontinued, the value of exercise for reducing the risk of depression, and the increased risk of fractures with the use of Z-drug hypnotics. Regarding clinical preventive services, adherence is better with fecal immunochemical tests than with older guaiac-based fecal occult blood tests for colon cancer screening; statins showed no benefit for patients 75 years or older; aspirin showed no benefit for cardiovascular disease prevention; and exercise, vision assessment, and environmental assessments may reduce the risk of falls. Finally, we identify the top POEMs summarizing clinical practice guidelines from the American College of Physicians, American College of Cardiology/American Heart Association, and the U.S. Preventive Services Task Force.
Annually, a group of experts in evidence-based medicine systematically review more than 110 English-language research journals to identify the evidence most likely to change primary care practice. The group includes physicians in the fields of family medicine, pharmacology, hospital medicine, and women’s health.1,2
The goal of this process is to identify POEMs (patient-oriented evidence that matters). A POEM must report patient-oriented outcomes, such as improvement in symptoms, morbidity, or mortality; be free of important methodologic bias; and recommend a change in practice for many physicians. Adopting valid POEMs in clinical practice could therefore result in improved patient outcomes. Of more than 20,000 research studies published in 2018 in the journals reviewed, 255 met the criteria for validity, relevance, and practice change.
The Canadian Medical Association (CMA) provides a subscription to POEMs for all of its members, who have the option to receive the daily POEM by e-mail. When members read the POEM, they can rate it with a validated tool called the Information Assessment Method. This tool addresses the domains of clinical relevance, cognitive impact, use in practice, and expected health benefits if that POEM was applied in patient care.3,4 Each POEM was rated by an average of 1,574 physicians.
In this article, we present the 20 POEMs that were rated highest for clinical relevance by CMA members in 2018. In this installment of our annual series (https://www.aafp.org/afp/toppoems), we summarize the clinical question and bottom-line answer for each research study identified as a top 20 POEM, organized by topic and followed by a brief discussion. We also present the five most relevant practice guidelines.
Our first group of POEMs focuses on hypertension (Table 1).5-9 Blood pressure measurement is a routine part of the physical examination in the office setting. Yet, POEM 1 shows that ambulatory blood pressure is considerably lower on average than office-based blood pressure, and that blood pressure readings from an ambulatory blood pressure device are more predictive of all-cause mortality than office-based blood pressure readings.5 Mortality is likely the outcome that matters most for patients.
|Clinical question||Bottom-line answer|
1. Which is a better predictor of mortality: ambulatory or office-based measurement of blood pressure?5
This study supports guidelines recommending that treatment decisions be based on ambulatory blood pressure monitoring rather than in-office blood pressure results. The difference between the two measurements in this cohort was 19/11 mm Hg, which is enough to change the decision to prescribe a medication at all or to add a second or third medication.
2. Is a single office blood pressure measurement reliable to assess hypertension?6
Do not rely on a single blood pressure measurement. The first blood pressure reading taken during an
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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, visit http://www.essentialevidenceplus.com.
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