Top POEMs of 2018 Consistent with the Principles of the Choosing Wisely Campaign


Am Fam Physician. 2019 Sep 1;100(5):290-294.

The full text of the POEMs discussed in this article is available at

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

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Additional Top POEMs from 2018 Consistent with the Principles of the Choosing Wisely Campaign

Clinical questionBottom-line answerClinical 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

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, Athens.

Address correspondence to Roland Grad, MD, MSc, 3755 Cote Sainte Catherine Rd., Montreal, Quebec, Canada H3T 1E2 (email: Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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1. Grad R, Pluye P, Tang D, et al. 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....

2. Morgan DJ, Dhruva SS, Coon ER, et al. 2018 update on medical overuse. JAMA Intern Med. 2019;179(2):240–246.

3. Grad R, Ebell MH. Top 20 research studies of 2018 for primary care physicians. Am Fam Physician. 2019;99(9):565–573. Accessed June 26, 2019.

4. Paavola M, Malmivaara A, Taimela S, et al.; Finnish Subacromial Impingement Arthroscopy Controlled Trial (FIMPACT) Investigators. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ. 2018;362:k2860.

5. Beard DJ, Rees JL, Cook JA, et al.; CSAW Study Group. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329–338.

6. Urquhart DM, Wluka AE, van Tulder M, et al. Efficacy of low-dose amitriptyline for chronic low back pain: a randomized clinical trial. JAMA Intern Med. 2018;178(11):1474–1481.

7. Vandvik PO, Lähdeoja T, Ardern C, et al. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. BMJ. 2019;364:l294.

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.

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.

12. Tait S, Kallogjeri D, Suko J, et al. Effect of budesonide added to large-volume, low-pressure saline sinus irrigation for chronic rhinosinusitis: a randomized clinical trial. JAMA Otolaryngol Head Neck Surg. 2018;144(7):605–612.

13. Carter A, Dattani N, Hannan SA. Chronic rhinosinusitis. BMJ. 2019;364:l131.

14. Bell KJ, Doust J, Glasziou P. Incremental benefits and harms of the 2017 American College of Cardiology/American Heart Association high blood pressure guideline. JAMA Intern Med. 2018;178(6):755–757.

15. Shah AS, Sandoval Y, Noaman A, et al. Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study [published correction appears in BMJ. 2018;360:k495]. BMJ. 2017;359:j4788.

16. Brunström M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis. JAMA Intern Med. 2018;178(1):28–36.

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



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