Top POEMs of 2019 Consistent with the Principles of the Choosing Wisely Campaign

 

Am Fam Physician. 2020 Dec 1;102(11):673-678.

  Related letter: Platelet-Rich Plasma Effective for Patients with Knee Osteoarthritis

Published online October 30, 2020.

Author disclosure: Dr. Grad has no relevant financial affiliations. Dr. Ebell is cofounder and editor-in-chief of Essential Evidence Plus; see Editor's Note.

In this article, we discuss the POEMs (patient-oriented evidence that matters) of 2019 judged to be most consistent with the principles of Choosing Wisely, an international campaign to reduce unnecessary testing and treatments. We selected these POEMs through a crowdsourcing strategy of the daily POEMs information service for the Canadian Medical Association's physician members. We present recommendations from these top POEMs of primary research or meta-analysis that identify interventions to encourage or consider avoiding in practice. The recommendations cover musculoskeletal conditions (e.g., do not recommend platelet-rich plasma injections for rotator cuff disease or knee osteoarthritis), respiratory disease (e.g., in clinically stable patients with community-acquired pneumonia, antibiotics can be stopped after five days), screening or preventive care (e.g., patients who take their blood pressure at home or in a pharmacy should know what to do when they have an elevated reading), and miscellaneous topics (e.g., in healthy adults treated for dermatophyte infection, do not obtain baseline or follow-up alanine transaminase level, aspartate transaminase level, or complete blood count). 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 patients engage in conversations better informed by high-quality evidence.

The coronavirus disease 2019 (COVID-19) pandemic has left its mark. Perhaps more than ever, we understand the importance of implementing the principles of the Choosing Wisely campaign in clinical practice to improve resource stewardship. Since 2016, articles in this series have highlighted POEMs (patient-oriented evidence that matters) as sparks to change practice, in line with the principles of the Choosing Wisely campaign.1 POEMs are synopses of research studies that report patient-oriented outcomes, such as improvement in symptoms, quality of life, or mortality. They describe studies that are free of important methodologic bias and recommend a change in practice for many physicians. In this article, we discuss the daily POEMs of 2019 that were judged to be most consistent with principles of the Choosing Wisely campaign, an international effort to reduce unnecessary medical tests, treatments, and procedures. Rather than having experts select the top POEMs, we use a crowd-sourcing method to identify new studies about clinical actions most consistent with Choosing Wisely, from the perspective of the physician in everyday practice.2

In brief, our crowdsourcing method to identify the top POEMs consistent with the Choosing Wisely campaign is based on ratings of the daily POEM delivered to physicians in a CME program. In 2019, we received an average of 1,530 physician ratings for each of the 254 POEMs delivered to members of the Canadian Medical Association. As identified by these physicians, we present the top POEMs of 2019 whose findings can help to reduce overdiagnosis or overtreatment in clinical practice.

Eleven of the top research studies of 2019 also ranked near the top for Choosing Wisely.3  Because these POEMs were summarized earlier this year in a related article, we do not rediscuss them here. However, to highlight their importance, POEMs on these studies are summarized in eTable A. In addition, all articles in the top POEMs series are available at https://www.aafp.org/afp/toppoems.

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eTABLE A

Additional Top POEMs from 2019 Consistent with the Principles of the Choosing Wisely Campaign

Clinical questionBottom-line answerClinical actions to consider for Choosing Wisely

In patients with acute pain, does a higher dose of ibuprofen produce greater pain relief?A1

Higher doses of ibuprofen for acute pain relief offer no more benefit at 60 minutes than a single 400-mg dose. The same has been shown for chronic treatment of osteoarthritis; an anti-inflammatory dose is not needed. Furthermore, another study showed equivalence between 200-mg and 400-mg doses of ibuprofen.

For pain relief, a 400-mg dose of ibuprofen works as well as higher doses.

What signs and symptoms are most useful for excluding the diagnosis of pneumonia in community-dwelling adults with an acute respiratory infection?A2

Community-dwelling adults who present as outpatients with symptoms of acute respiratory tract infection but normal vital signs and normal findings on a pulmonary examination have only a 0.4% likelihood of community-acquired pneumonia.

The combination of normal vital signs and normal lung examination findings essentially rules out community-acquired pneumonia.

Does low-dose aspirin prevent cardiovascular events and cardiovascular-related death in otherwise healthy older people?A3

Low-dose aspirin does not reduce the

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.

Author disclosure: Dr. Grad has no relevant financial affiliations. Dr. Ebell is cofounder and editor-in-chief of Essential Evidence Plus; see Editor's Note.

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

References

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2. 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.

3. Ebell MH, Grad R. Top 20 research studies of 2019 for primary care physicians. Am Fam Physician. 2020;101(10):608–617. Accessed September 3, 2020. https://www.aafp.org/afp/2020/0515/p608.html

4. Gong J, Colligan M, Kirkpatrick C, et al. Oral paracetamol versus combination oral analgesics for acute musculoskeletal injuries. Ann Emerg Med. 2019;74(4):521–529.

5. Hurley ET, Hannon CP, Pauzenberger L, et al. Nonoperative treatment of rotator cuff disease with platelet-rich plasma: a systematic review of randomized controlled trials. Arthroscopy. 2019;35(5):1584–1591.

6. Di Martino A, Di Matteo B, Papio T, et al. Platelet-rich plasma versus hyaluronic acid injections for the treatment of knee osteoarthritis: results at 5 years of a double-blind, randomized controlled trial. Am J Sports Med. 2019;47(2):347–354.

7. Rutjes AW, Jüni P, da Costa BR, et al. Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis. Ann Intern Med. 2012;157(3):180–191.

8. Jevsevar D, Donnelly P, Brown GA, et al. Viscosupplementation for osteoarthritis of the knee: a systematic review of the evidence. J Bone Joint Surg Am. 2015;97(24):2047–2060.

9. Butler CC, Gillespie D, White P, et al. C-reactive protein testing to guide antibiotic prescribing for COPD exacerbations. N Engl J Med. 2019;381(2):111–120.

10. Stefan MS, Shieh MS, Spitzer KA, et al. Association of antibiotic treatment with outcomes in patients hospitalized for an asthma exacerbation treated with systemic corticosteroids. JAMA Intern Med. 2019;179(3):333–339.

11. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45–e67.

12. Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a multihospital cohort study. Ann Intern Med. 2019;171(3):153–163.

13. Tansarli GS, Mylonakis E. Systematic review and meta-analysis of the efficacy of short-course antibiotic treatments for community-acquired pneumonia in adults. Antimicrob Agents Chemother. 2018;62(9): e00635–18.

14. Lee JM, Arao RF, Sprague BL, et al. Performance of screening ultrasonography as an adjunct to screening mammography in women across the spectrum of breast cancer risk [published correction appears in JAMA Intern Med. 2019;179(5):733]. JAMA Intern Med. 2019;179(5):658–667.

15. Manson JE, Cook NR, Lee IM, et al.; VITAL Research Group. Marine n-3 fatty acids and prevention of cardiovascular disease and cancer. N Engl J Med. 2019;380(1):23–32.

16. Bowman L, Mafham M, Wallendszus K, et al.; ASCEND Study Collaborative Group. Effects of n-3 fatty acid supplements in diabetes mellitus. N Engl J Med. 2018;379(16):1540–1550.

17. Nerenberg KA, Zarnke KB, Leung AA, et al. Hypertension Canada's 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Can J Cardiol. 2018;34(5):506–525.

18. Atzema CL, Wong A, Masood S, et al. The characteristics and outcomes of patients who make an emergency department visit for hypertension after use of a home or pharmacy blood pressure device. Ann Emerg Med. 2018;72(5):534–543.

19. Yasuda S, Kaikita K, Akao M, et al.; AFIRE Investigators. Antithrombotic therapy for atrial fibrillation with stable coronary disease. N Engl J Med. 2019;381(12):1103–1113.

20. Stolmeier DA, Stratman HB, McIntee TJ, et al. Utility of laboratory test result monitoring in patients taking oral terbinafine or griseofulvin for dermatophyte infections. JAMA Dermatol. 2018;154(12):1409–1416.

21. Balk EM, Rofeberg VN, Adam GP, et al. Pharmacologic and nonpharmacologic treatments for urinary incontinence in women: a systematic review and network meta-analysis of clinical outcomes. Ann Intern Med. 2019;170(7):465–479.

22. Thiels CA, Habermann EB, Hooten WM, et al. Chronic use of tramadol after acute pain episode: cohort study. BMJ. 2019;365:l1849.

23. Schnadower D, Tarr PI, Casper TC, et al. Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. N Engl J Med. 2018;379(21):2002–2014.

24. Strawbridge R, Carter B, Marwood L, et al. Augmentation therapies for treatment-resistant depression: systematic review and meta-analysis. Br J Psychiatry. 2019;214(1):42–51.

25. Feizizadeh S, Salehi-Abargouei A, Akbari V. Efficacy and safety of Saccharomyces boulardii for acute diarrhea. Pediatrics. 2014;134(1):e176–e191.

 

 

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