Top POEMs of 2018 Consistent with the Principles of the Choosing Wisely Campaign
Am Fam Physician. 2019 Sep 1;100(5):290-294.
Author disclosure: No relevant financial affiliations.
In this article, we discuss the POEMs (patient-oriented evidence that matters) of 2018 judged to be most consistent with the principles of the Choosing Wisely campaign. We selected these POEMs through a crowdsourcing strategy of the daily POEMs information service for Canadian Medical Association's physician members. We present recommendations from these top POEMs of primary research or meta-analysis that identify interventions to consider avoiding in practice. The recommendations cover musculoskeletal conditions (e.g., avoid decompression surgery for treatment of subacromial shoulder pain), respiratory disease (in mild asthma, do not routinely prescribe a long-term daily inhaled steroid over the as-needed use of budesonide/formoterol), infections (e.g., in children with acute respiratory tract infection, do not routinely prescribe broad-spectrum antibiotics over narrow-spectrum antibiotics), and cardiovascular disease (e.g., avoid blanket testing of cardiac troponin in patients with a low pretest likelihood of myocardial infarction). 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 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 this article, we discuss the POEMs of 2018 that were most consistent with 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, our crowdsourcing method allows us to identify new studies about clinical actions most consistent with Choosing Wisely, from the perspective of the physician in everyday practice.1,2
In brief, our crowdsourcing method to identify the top POEMs of 2018 consistent with Choosing Wisely is based on physician ratings of the daily POEMs delivered in the context of a continuing medical education program. On average, we received 1,574 physician ratings for each of the 255 unique POEMs in 2018 delivered to members of the Canadian Medical Association. Using these ratings, we compiled a list of top POEMs, which we previously summarized in American Family Physician.3 In this article, we now present the top POEMs of 2018 whose findings were judged to help reduce overdiagnosis or overtreatment in clinical practice and are thus consistent with the principles of the Choosing Wisely campaign.
Note that 13 of the top POEMs of 2018 also ranked at the top for Choosing Wisely. We do not rediscuss these POEMs in this article, but they are summarized in eTable A. In addition, all articles in the top POEMs series are available at https://www.aafp.org/afp/toppoems.
Additional Top POEMs from 2018 Consistent with the Principles of the Choosing Wisely Campaign
|Clinical question||Bottom-line answer||Clinical actions to consider for Choosing Wisely|
Which is a better predictor of mortality: ambulatory or office-based blood pressure measurement?A1
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.
In patients with elevated blood pressure, do not empirically treat without considering the use of an ambulatory monitor to clarify prescribing decisions.
Is a single office-based blood pressure measurement reliable to assess hypertension?A2
Do not rely on a single blood pressure measurement. The first blood pressure reading taken during an office visit will be substantially different than subsequent readings in almost one-half of typical patients and, if relied on, will result in one out of eight patients being falsely labeled as hypertensive.
In patients with elevated blood pressure, do not rely on a single blood pressure measurement.
In patients with high blood pressure, does a second reading show lower results?A3
If you are not rechecking high blood pressures, you should. Set your electronic health record to prompt you to do it. In this large study, when reminded, clinicians rechecked elevated blood pressures 83% of the time, finding a median drop in blood pressure of 8 mm Hg during the same visit. That drop is equivalent to a typical reduction in blood pressure with pharmacologic treatment over time and resulted in o
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8. O'Byrne PM, FitzGerald JM, Bateman ED, et al. Inhaled combined budesonide-formoterol as needed in mild asthma. N Engl J Med. 2018;378(20):1865–1876.
9. Bateman ED, Reddel HK, O'Byrne PM, et al. As-needed budesonide-formoterol versus maintenance budesonide in mild asthma. N Engl J Med. 2018;378(20):1877–1887.
10. Global Initiative for Asthma. Global strategy for asthma management and prevention. Updated 2019. Accessed July 11, 2019. https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf
11. Gerber JS, Ross RK, Bryan M, et al. Association of broad- vs narrow-spectrum antibiotics with treatment failure, adverse events, and quality of life in children with acute respiratory tract infections. JAMA. 2017;318(23):2325–2336.
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17. Mitchell CM, Reed SD, Diem S, et al. Efficacy of vaginal estradiol or vaginal moisturizer vs placebo for treating postmenopausal vulvovaginal symptoms: a randomized clinical trial. JAMA Intern Med. 2018;178(5):681–690.
18. Lipska KJ, Parker MM, Moffet HH, et al. Association of initiation of basal insulin analogs vs neutral protamine hagedorn insulin with hypoglycemia-related emergency department visits or hospital admissions and with glycemic control in patients with type 2 diabetes. JAMA. 2018;320(1):53–62.
19. Poonai N, Datoo N, Ali S, et al. Oral morphine versus ibuprofen administered at home for postoperative orthopedic pain in children: a randomized controlled trial. CMAJ. 2017;189(40):E1252–E1258.
20. Santer M, Ridd MJ, Francis NA, et al. Emollient bath additives for the treatment of childhood eczema (BATHE): multicentre pragmatic parallel group randomised controlled trial of clinical and cost effectiveness. BMJ. 2018;361:k1332.
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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