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Am Fam Physician. 2017;96(9):565-566

Original Article: Top POEMs of 2015 Consistent with the Principles of the Choosing Wisely Campaign

Issue Date: October 1, 2016

to the editor: I applaud the main intent of this article: using current evidence to critically assess testing and treatments for common conditions in family medicine. I am a fan of the daily POEMs (patient-oriented evidence that matters) series, and I regularly distribute them to my residents.

I have a question about the process of selecting articles to be POEMs. Are the articles themselves “chosen wisely”? This is most important when a single article is selected from a larger body of evidence and used to support a recommendation for practice.

For example, the article cited a randomized controlled trial (RCT) with 192 patients 1 and advised readers “… do not prescribe platelet-rich plasma injections over hyaluronic acid.” However, this is only one among numerous RCTs addressing the subject of platelet-rich plasma injections for osteoarthritis of the knee.

There are two meta-analyses of several RCTs (seven RCTs, N = 722 patients 2 and six RCTs, N = 739 patients 3) and a systematic review 4 with multiple meta-analyses (each with six to 16 RCTs and totals of 577 to 1,543 patients) all evaluating the same question. Although the meta-analyses overlap to some extent (some of the same RCTs are included in each meta-analysis), in general, they found that platelet-rich plasma injections reduced knee pain scores by approximately 25% more than hyaluronic acid for several months. This is a different conclusion than that of the single RCT discussed in this article.

Would it be possible to alter the methodology of the POEMs selection process and describe single studies in the context of the larger body of evidence?

in reply: Thank you for asking about the process of selecting articles to become POEMs. This is related to your concern about how to know when the evidence is ripe enough to support a change of practice.

Whereas some POEMs are based on single research studies within a larger body of evidence, knowing when POEM evidence is strong enough to spark a change of practice can be challenging. Of note, in Tables 1 through 4, we did specify that these are “clinical actions to consider for Choosing Wisely.” This is in line with the accompanying editorial, which stated that the Choosing Wisely campaign “identifies wasteful and unnecessary medical tests, treatments, and procedures—not to prohibit them but to get physicians and other health care professionals thinking more critically….” 1

Concerning your main question, in the methods section of a previous article, we provided information describing how POEMs are selected. Briefly, this process begins with a search of the tables of contents of 102 journals for original research or systematic reviews. In the discussion section of this same paper, we wrote: “A second limitation of this work is related to the process of selecting research articles for the creation of POEMs. A primary research study or systematic review that never became a POEM would not be rated in the ongoing CME program. … The extent of any selection bias in the identification of ‘POEM-worthy’ articles is unknown and therefore is a subject for research.” 2

We currently do not include Arthroscopy as one of the journals reviewed each month, but we will certainly consider adding it. Systematic reviews are often covered in POEMs, and we place high value on them as a way to synthesize the literature and help family physicians and their patients make more informed decisions. On the other hand, not all systematic reviews are of high quality; some have weak methodology or authors with conflicts of interest.3

You also ask about describing single studies in the context of the larger body of evidence. POEMs often provide some context or mention other studies. However, making them much longer (i.e., essentially writing a mini review article) would defeat the purpose by making them too long to read quickly. The POEMs provide overviews of common medical topics by the authors and editors who contribute and sustain knowledge resources, such as Essential Evidence Plus.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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