Am Fam Physician. 2018;98(2):93-98
Author disclosure: Dr. Grad has no relevant financial affiliations. Dr. Ebell is cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. See Editor's Note.
This article discusses the POEMs (patient-oriented evidence that matters) of 2017 judged to be most consistent with the principles of the Choosing Wisely campaign. A POEM 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. We selected these POEMs through a crowdsourcing strategy of the daily POEMs information service for physician-members of the Canadian Medical Association. Recommendations are presented from these top POEMs of primary research or meta-analysis as interventions to consider avoiding in practice. The recommendations cover musculoskeletal conditions (e.g., avoid arthroscopy for initial treatment of a meniscal tear), respiratory disease (e.g., avoid screening for lung cancer without informing your patient of the risk of a false-positive test result), infections (e.g., do not routinely add trimethoprim/sulfamethoxazole to cephalexin for nonpurulent uncomplicated cellulitis), and cardiovascular disease (e.g., do not prescribe niacin, alone or in combination with a statin, to prevent cardiovascular disease). 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 that are 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 a popular continuing medical education program, physician members of the Canadian Medical Association receive the daily POEM and rate each one using a brief validated questionnaire. From these ratings, each year we select the daily POEMs that are most consistent with the 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,1 this crowdsourcing method allows us to identify new research studies about clinical actions most consistent with Choosing Wisely, from the perspective of physicians in everyday practice.2
From the data, we identified the top POEMs of primary research or meta-analysis where physicians said that study findings would help them to reduce overdiagnosis or over-treatment in clinical practice. We excluded 13 of the most relevant POEMs of 2017 because they were previously discussed in American Family Physician.5 However, to highlight their importance, these POEMs are available online (eTable A). Below, we organize the top POEMs for Choosing Wisely by condition and accompany each one with a brief discussion. We also discuss implications for decision making based on one of the most relevant clinical practice guidelines of 2017.
|Clinical question||Bottom-line answer||Clinical actions to consider for Choosing Wisely|
|Is confirmatory diagnostic testing cost-effective for the management of clinically suspected onychomycosis?A1||The most cost-effective approach to a patient with clinically suspected onychomycosis is empiric therapy with oral terbinafine (Lamisil). The chance of liver injury is estimated to be only one in 50,000 to one in 120,000, so testing to confirm the diagnosis would cost tens of millions of dollars per case of liver injury avoided. If you plan to prescribe the less effective and much more expensive topical solution efinaconazole (Jublia), then confirmatory testing with periodic acid-Schiff stain reduces costs.||If you are going to prescribe oral terbinafine, consider empiric therapy without confirmatory testing because it may be just as safe and is more cost-effective.|
|Is pregabalin (Lyrica) an effective treatment for the pain of acute or chronic sciatica?A2||Pregabalin does not relieve pain in patients with sciatica. This study randomized 207 patients with moderate to severe sciatica, and followed them for one year. The authors concluded that pregabalin does not relieve pain, improve function, or improve any other outcomes in patients with sciatica.||In patients with sciatica, do not routinely prescribe gabapentinoids such as pregabalin.|
|Do intra-articular corticosteroids improve pain and function and decrease cartilage loss in adults with osteoarthritis of the knee?A3||This well-done study found that regular three-month intra-articular injections of triamcinolone for two years resulted in no significant difference in pain and function assessments compared with saline. However, a significant increase in cartilage loss and damage occurred in patients receiving corticosteroids compared with saline.||In patients with knee osteoarthritis, do not routinely inject triamcinolone every three months to improve pain or function.|
|Is there a clinical benefit to treating subclinical hypothyroidism in older adults?A4||Treatment of patients with a minimally elevated thyroid-stimulating hormone (TSH) level did not result in any improvement in symptoms. If patients present with a TSH level between 4.6 and 10 mIU per L, repeat the test because levels often normalize (this occurred in 60% of the patients initially referred for the study). Only consider treatment if levels increase to greater than 10.0 mIU per L.||In adults 65 years and older, do not routinely treat subclinical hypothyroidism.|
|What is the best way to measure blood pressure?A5||To get the most accurate measure, let patients relax for a few minutes, and then measure their blood pressure on a completely bare arm. Does a difference of 4 mm Hg systolic and 6 to 7 mm Hg diastolic matter? It might, especially when deciding whether to add a second or third drug.||In older patients, do not measure blood pressure over an arm covered by a sleeve or with the sleeve rolled up.|
|Does home monitoring of blood glucose levels improve glycemic control or quality of life in patients with type 2 diabetes who are not taking insulin?A6||Lots of numbers, money, and strips in landfills, with little to show for it. Home glucose monitoring of patients in primary care does not improve A1C levels or quality of life over one year in patients who are not taking insulin. Patients did not feel more empowered or satisfied as a result of home monitoring, nor did they have fewer hypoglycemic episodes. Additionally, their physicians did not seem to respond to the home glucose levels to any beneficial effect.||In most persons with type 2 diabetes, do not routinely recommend home monitoring of blood glucose levels.|
|In patients with mild to moderate ankle sprain, does physical therapy (physiotherapy) hasten or improve recovery?A7||Physical therapy (up to seven sessions) does not hasten resolution of symptoms or improve function in adults with ankle sprain. Approximately 60% of patients who receive usual care or physical therapy do not achieve excellent resolution. Send patients home with the usual RICES protocol: rest, ice, compression, elevation, and splinting.||In adults with mild to moderate ankle sprain, do not refer all patients for physiotherapy.|
|Are gabapentinoids safe and effective in treating patients with chronic low back pain?A8||The existing data on gabapentinoids for chronic low back pain are limited in number and quality. The amount of pain reduction is low to moderate, whereras the rate of adverse effects is high. The few studies that assessed function found no improvement.||In adults with back pain of at least three months duration, do not recommend gabapentinoids to improve functional outcomes.|
|Does positive airway pressure for adults with sleep apnea reduce cardiovascular disease morbidity and mortality?A9||The use of positive airway pressure in adults with sleep apnea does not reduce adverse cardiovascular events or mortality. Patients who experience daytime fatigue at baseline benefit from reduced sleepiness and improved physical and mental well-being. Order sleep testing only in patients with signs or symptoms of sleep apnea who also experience clinically significant symptoms of daytime fatigue.||In adults with sleep apnea, do not recommend continuous positive airway pressure to reduce cardiovascular events or mortality.|
|When should treatment be initiated in older patients with hypertension, and what are reasonable |
|Try to remember 60–150–140: In patients older than 60 years, consider treatment if the systolic blood pressure is 150 mm Hg or higher, or 140 mm Hg or higher in patients with a history of stroke or transient ischemic attack and in those at high cardiovascular risk. The guideline suggests initiating therapy only after a discussion of the benefits and risks with each patient; physicians should avoid making treatment decisions based just on the numbers.||In adults older than 60 years, do not routinely initiate antihypertensive treatment when systolic blood pressure is between 140 and 150 mm Hg.|
|How do older patients react to the idea of stopping cancer screening toward the end of life?A11||When bringing up the idea that cancer screening may no longer be beneficial given a patient's limited life expectancy, using direct language such as “You may not live long enough to benefit from this test” is perceived by many patients as overly harsh. Instead, statements such as “This test will not help you live longer” may be better received. Although not studied, this same approach may be helpful for deprescribing efforts.||In older patients, do not discuss the idea that cancer screening may no longer be beneficial using language such as “You may not live long enough to benefit from this test.”|
|Does screening of asymptomatic men for prostate cancer improve mortality?A12||There is still no evidence of mortality benefit from prostate cancer screening in the PLCO Cancer Screening Trial. After nearly two decades of follow-up from the PLCO Cancer Screening Trial, there appears to be no mortality benefit to screening asymptomatic men for prostate cancer. These findings are limited to some extent by contamination. (About one-half of the men assigned to no screening had at least one prostate-specific antigen test during the study period.)||In asymptomatic men 55 to 69 years of age, do not recommend screening for prostate cancer unless the patient understands the limitations of prostate-specific antigen screening and makes a personal decision that a small possibility of benefit outweighs the known risk of harms.|
|What is the long-term effect of intensive blood glucose control in patients with type 2 diabetes?A13||The initial Action to Control Cardiovascular Risk in Diabetes (ACCORD) study, which compared standard treatment (A1C target of 7.0% to 7.9%) with intensive control (A1C target of 6.0%), found that, despite good intentions, cardiovascular and overall mortality are significantly higher when blood glucose levels are lower. This study, which followed patients for an additional five years, found that patients in the intensive treatment group continued to keep their A1C levels lower than in the standard care group; however, they also continued to be at increased risk of death from a cardiovascular event.||In adults with type 2 diabetes, do not recommend intensive control of blood glucose to prevent cardiovascular disease.|
The first group of POEMs focuses on the treatment of musculoskeletal conditions: meniscal tears, shoulder pain, osteoporosis, osteoarthritis of the knee, and low back pain (Table 1).6–10 In 2017, a systematic review of nine clinical trials confirmed that arthroscopic meniscectomy for a degenerative tear is no better than a nonoperative approach involving exercise or physical therapy.6 This finding is consistent with the bottom line of POEMs from 2015 and 2016, as summarized in the previous installments of this series.3,4 Despite this knowledge, surgeons continue to perform the procedure in older persons.11
|POEM title||Clinical actions to consider for Choosing Wisely|
|Arthroscopic meniscal surgery = nonoperative management6||In patients with knee pain and a degenerative meniscal tear, do not recommend arthroscopic surgery for the outcomes of improved long-term pain or function before a trial of conservative management.|
|Radial extracorporeal shock wave therapy = sham therapy for subacromial shoulder pain7||In patients with subacromial shoulder pain receiving supervised exercise therapy, do not add radial extracorporeal shock wave therapy to improve their symptoms.|
|Long-term use of bisphosphonates increases the risk of fractures in older women8||In elderly women already receiving bisphosphonates for primary prevention of fragility fracture, do not recommend such treatment for more than five years.|
|Placebo more effective than glucosamine plus chondroitin sulfate for knee degenerative joint disease9||In adults with radiographically moderate to severe knee degenerative joint disease and moderate to severe pain, do not expect glucosamine plus chondroitin to improve pain and function more than a placebo.|
|Diazepam adds little to NSAID treatment for acute low back pain10||In patients with uncomplicated low back pain of less than two weeks duration; do not add diazepam to naproxen, 500 mg twice daily, to further reduce pain.|
Subacromial shoulder pain is common in middle-aged persons. It is located near the top and lateral side of the shoulder. A properly conducted randomized controlled trial (RCT) showed no benefit to symptoms from adding radial extracorporeal shock wave therapy to supervised exercise therapy.7
A 2017 guideline from the American College of Physicians that was endorsed by the American Academy of Family Physicians (AAFP) recommends treating adults who have osteoporosis and no known fragility fracture with a bisphosphonate for no more than five years.12,13 An observational study using data from the Women's Health Initiative supports this recommendation. This cohort study found a higher risk of clinical fracture among women who used bisphosphonates for 10 to 13 years compared with women who received bisphosphonates for two years (hazard ratio = 1.29; 95% confidence interval, 1.07 to 1.57).8
Many patients with osteoarthritis of the knee self-medicate with glucosamine and chondroitin. An industry-funded RCT of glucosamine plus chondroitin was stopped after six months when the data safety monitoring board judged the placebo intervention to be better at improving pain or function.9 Harms were similar in both groups. Because glucosamine and chondroitin are sold as herbal supplements and are not regulated by the U.S. Food and Drug Administration, some preparations may be more effective than others.
Given the muscle spasm that accompanies acute low back pain, a common practice is to prescribe muscle relaxants such as cyclobenzaprine (Flexeril) or diazepam (Valium). In persons already taking naproxen for acute low back pain, adding diazepam does not improve disability or pain scores.10
Two POEMs focus on screening for lung cancer and over-treatment of asthma (Table 2).14,15 The National Lung Screening Trial found a reduction in disease-specific and all-cause mortality with lung cancer screening.16 Subsequently, the Canadian Task Force on Preventive Health Care17 and U.S. Preventive Services Task Force18 voted in favor of lung cancer screening in select high-risk populations (e.g., older adults with at least a 30 pack-year smoking history), although the AAFP found insufficient evidence to recommend screening.19 Some family physicians have started to offer lung cancer screening, but concern about the high rate of false-positive results (and other harms, such as radiation exposure, overdiagnosis, and incidental non-lung findings) suggest that there is no single correct choice. In a cohort of primary care patients in the Veterans Health Administration system, 97.5% of patients with an abnormal computed tomography result did not have lung cancer.14 This finding suggests that shared decision making is appropriate given the burden of false-positive results and subsequent follow-up.20 High-quality lung cancer screening decision aids for patients and clinicians are available from the Agency for Healthcare Research and Quality at https://effectivehealthcare.ahrq.gov/decision-aids/lung-cancer-screening/home.html.
|POEM title||Clinical actions to consider for Choosing Wisely|
|High false-positive rate with lung cancer screening14||Do not order low-dose computed tomography to screen for lung cancer without informing your patient of the risk of a false-positive test result.|
|One-third of adults with diagnosed asthma can be weaned off all asthma meds15||In patients not confirmed to have asthma with either baseline spirometry or serial bronchial challenge testing, as many as one-third can be safely weaned off their daily asthma medication.|
Uncertainty about a patient's diagnosis of asthma should increase in the absence of formal testing with spirometry. In a population-based study of 613 adults 18 years or older who were thought to have asthma, 203 patients (33%) had a formal diagnosis of asthma ruled out after spirometry and bronchial challenge testing.15 Those confirmed not to have asthma after spirometry or serial bronchial challenge testing had their asthma medications gradually tapered and discontinued, if possible, over four study visits. After one year of follow-up, only six (3%) of these patients returned with respiratory symptoms and resumed treatment. The take-home message is to confirm the diagnosis of asthma in patients who have never undergone formal testing.
|POEM title||Clinical actions to consider for Choosing Wisely|
|Oral steroids not helpful for acute lower respiratory tract infection in nonasthmatic adults21||In adults 18 years or older with no chronic pulmonary disease or asthma seen in the outpatient setting, do not prescribe prednisone for an acute cough (28 days or less) and at least one other lower respiratory tract symptom (e.g., phlegm, chest pain, wheezing, or shortness of breath).|
|Tubes ineffective for treating otitis media in children22||Do not recommend tympanostomy tubes for sustained improved hearing in children with recurrent otitis media with effusion.|
|No benefit with addition of TMP/SMX to cephalexin for nonpurulent cellulitis23||Do not routinely add TMP/SMX to cephalexin (Keflex) for nonpurulent uncomplicated cellulitis.|
In patients with respiratory tract infection, it is tempting to treat symptoms of wheezing in the outpatient setting. A well-designed RCT identified 401 patients with respiratory tract infection and at least one other lower respiratory tract symptom (e.g., phlegm, chest pain, wheezing, shortness of breath). These patients had no evidence of chronic obstructive pulmonary disease and no prescription for asthma in the previous five years. They were randomized to 40 mg of prednisolone daily for five days or placebo. Treatment yielded no difference between groups in duration of cough or severity of symptoms, even in those who had wheeze on presentation.21
For children with recurrent otitis media or chronic effusion, many of us were taught that tympanostomy tubes are indicated to prevent delay in language acquisition. However, a meta-analysis of 16 RCTs with children who had otitis media with effusion found no hearing benefit from this surgical intervention after 12 to 24 months.22 Will this contribute to a change in otolaryngology referral for our preschoolers? At the very least, we should share this information with parents who ask about tympanostomy tubes.
Given the prevalence of methicillin-resistant Staphylococcus aureus, trimethoprim/sulfamethoxazole is increasingly prescribed in some communities for patients with skin structure infections. In an RCT of 500 patients who presented to the emergency department with nonpurulent uncomplicated cellulitis, covering for methicillin-resistant S. aureus and streptococci with trimethoprim/sulfamethoxazole did not improve rates of clinical cure compared with cephalexin (Keflex) alone.23 Of note, physicians in this study used bedside ultrasonography to exclude patients with abscess. Providing early follow-up for patients in the emergency department who do not respond to cephalexin is an approach consistent with antimicrobial stewardship.
Cardiovascular Disease Prevention
Two POEMs focus on preventing cardiovascular disease (Table 4).24,25 Although niacin may increase high-density lipoprotein cholesterol levels, no patient-oriented outcomes are improved by adding this treatment in the statin era. This was the finding of a meta-analysis of trials comparing niacin with placebo, either alone or in combination with statin treatment.24 The test of time has confirmed these results, which are consistent with other meta-analyses of niacin or fibrates.26 However, in patients with intolerance to statins, the American College of Cardiology/American Heart Association still recommend that nonstatin drugs be considered.27
|POEM title||Clinical actions to consider for Choosing Wisely|
|Niacin does not decrease mortality in patients with CAD or low HDL24||In patients with or at risk of coronary artery disease, do not prescribe niacin, either alone or in combination with a statin, to prevent cardiovascular mortality, nonfatal myocardial infarction, stroke, or the need for revascularization.|
|Lipid treatment for primary prevention not effective in older adults25||Do not initiate a statin in persons older than 65 years with no clinically apparent cardiovascular disease without an attempt at shared decision making.|
As briefly mentioned in the top 20 research articles of 2017,5 one of the most highly rated guidelines of the year for relevance to practice was from the U.S. Preventive Services Task Force.28 This guideline recommended that adults without a history of cardiovascular disease (CVD) use a low- to moderate-dose statin for the primary prevention of CVD events and mortality when all of the following criteria are met: (1) they are 40 to 75 years of age; (2) they have one or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking); and (3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater.
Many persons 65 to 74 years of age have an estimated 10-year CVD risk greater than 10%, using the Framingham calculator.29 Yet the top POEM of 2017 consistent with Choosing Wisely, which was also one of the top 20 research articles of 2017,5 was the lipid-lowering trial component of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. In a post-hoc analysis, there was no benefit to statins for primary cardiovascular prevention in persons 65 to 74 years of age.25 This finding, with the absence of direct trial evidence of benefit from statins for primary prevention of CVD in older persons, may have an impact on future guidelines. For now, a shared decision about initiating statin treatment in patients older than 65 years and no clinically apparent coronary disease seems most reasonable.
The remaining two POEMs do not fit neatly into one category but provide useful guidance for Choosing Wisely (Table 5).30,31 First, adding prednisone to antihistamines offers no added benefit for the acute treatment of simple urticaria. This finding came from an RCT of 100 adults who presented to an emergency department with a generalized rash for less than one day characterized by fleeting wheals and itching but without angioedema or anaphylaxis.30 All patients were treated with the antihistamine levocetirizine (Xyzal), 5 mg daily for five days, and randomized to additionally receive placebo or prednisone, 40 mg daily for four days. On follow-up by telephone, 62% of patients treated with antihistamine/prednisone and 76% receiving antihistamine/placebo were asymptomatic (difference not significant). Relapse of urticaria was similar in both groups.
|POEM title||Clinical actions to consider for Choosing Wisely|
|Steroid treatment adds no benefit to antihistamines for acute hives30||Do not add prednisone to an antihistamine for simple acute urticaria.|
|The Quick-Wee method gets infant urine flowing31||In infants from whom a clean-catch urine sample is needed, do not attempt catheterization without at least considering the Quick-Wee method (gentle cutaneous suprapubic stimulation using gauze soaked in refrigerated saline).|
Finally, is there an effective, noninvasive way to quickly collect a successful urine sample from infants? An RCT of 354 infants one to 12 months of age showed the Quick-Wee method to be simple and effective while avoiding a catheter for a urine sample. Compared with the wait-and-catch strategy, the Quick-Wee method (gentle cutaneous suprapubic stimulation using gauze soaked in refrigerated saline) improved the chance of successfully collecting a urine sample in a specimen cup (30% vs. 9% of the time), with no change in the rate of contamination.31
Editor's Note: This article was cowritten by Dr. Mark Ebell, Deputy Editor for Evidence-Based Medicine in AFP, and cofounder and Editor-in-Chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. Because of Dr. Ebell's dual roles and ties to Essential Evidence Plus, the article underwent peer review and editing by three of AFP's medical editors. Dr. Ebell was not involved in the editorial decision-making process.— Sumi M. Sexton, MD, Editor-in-Chief, American Family Physician