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

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

Published online October 30, 2020.

This clinical content conforms to AAFP criteria for CME.

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.

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 likelihood that these patients will experience a major cardiovascular event during nearly five years of follow-up.Do not use low-dose aspirin for the primary prevention of cardiovascular events in otherwise healthy older adults.
Does aspirin improve disability-free survival in otherwise healthy older people?A4 In this landmark study of a contemporary population, in which risk factors such as hyperlipidemia and hypertension are more likely to be addressed, aspirin did not provide a benefit in terms of death, dementia, or disability in a group of largely White older patients.Do not use aspirin for noncardiovascular primary prevention in otherwise healthy older adults.
How long do colds last in children?A5 Most respiratory illnesses in children are mild, do not require medical care, and do not result in school absences; however, symptoms can last up to three weeks.Because cold symptoms can last up to three weeks, clinicians should counsel parents of children with respiratory symptoms to be patient.
Can strep throat in children and adults be treated with five days of oral penicillin V?A6 Five days of penicillin V, 800 mg four times per day, was not inferior to 10 days of penicillin V, 1,000 mg three times per day, with shorter symptom duration. This is not the first study to show similar benefits with a shorter duration of oral amoxicillin/clavulanate (Augmentin), amoxicillin, or a cephalosporin.Consider a five-day course of higher-dose penicillin V for symptom relief in patients with streptococcal pharyngitis.
Are statins effective in patients older than 75 years?A7 Statins are effective in preventing major coronary events in patients older than 75 years, but this effect is significant only in those with established cardiovascular disease. This is consistent with the results from the ALLHAT trial, which also showed no benefit for primary prevention and additionally showed a trend toward harm in those older than 75 years.In patients older than 75 years without cardiovascular disease, do not initiate statins for primary prevention.
Is fully automated blood pressure measurement more accurate than manual sphygmomanometry?A8 There are two takeaways from this analysis. (1) Automated measurement aligns better with ambulatory blood pressure monitoring (the best predictor of cardiovascular events) than manual measurement. (2) Manual readings are an average of 13.4 to 14.5 mm Hg (systolic) higher than daytime ambulatory or automated readings in patients with hypertension.Use automated blood pressure measurements to guide treatment decisions.
What is the yield of a screening program based on FIT every two years for 10 years?A9 Over 10 years, the detection rates for colorectal cancer and advanced adenomas using FIT are similar to those seen in studies of screening colonoscopy. This is reassuring, but it does not prove that FIT reduces morbidity and mortality due to colorectal cancer as effectively as colonoscopy. Modeling concludes that a FIT-based screening program will result in one-half as many colonoscopies as a colonoscopy-based program, as well as a significant reduction in cost, burden, and harm of screening.For colorectal cancer screening, consider FIT testing because it compares favorably with colonoscopy.
Does a lack of early symptom improvement in patients treated for depression predict treatment failure?A10 Response to treatment within the first two weeks predicts eventual response or remission, but a lack of early response does not predict treatment failure. Approximately one-third of patients who do not show an early response will respond by six weeks. No individual symptom response predicts eventual improvement.Stay the course with depression treatment; one-third of early nonresponders responded by six weeks of treatment.
Is modern FIT for occult blood in the stool less accurate in patients who are taking aspirin, an anticoagulant, or a nonsteroidal anti-inflammatory drug?A11 The use of these drugs has no clinically important effects on the positive predictive value of FIT in a screening population.Do not avoid FIT testing in patients taking aspirin, oral anticoagulants, or nonsteroidal anti-inflammatory drugs. These drugs do not reduce test accuracy.

Musculoskeletal Conditions

The first group of POEMs focuses on the treatment of musculoskeletal conditions (Table 1).46

POEM titleClinical actions to consider for Choosing Wisely
Adding ibuprofen and codeine to acetaminophen does not improve pain relief for acute musculoskeletal injury4 For patients with acute musculoskeletal injury pain, consider acetaminophen (or a nonsteroidal anti-inflammatory drug) alone, rather than in combination with an opioid.
Platelet-rich plasma injection is not beneficial for nonoperative treatment of rotator cuff disease5 Do not recommend platelet-rich plasma injections for patients with nonoperative rotator cuff disease.
After five years, platelet-rich plasma = hyaluronic acid injections for patients with knee osteoarthritis6 Do not recommend platelet-rich plasma injections for patients with knee osteoarthritis because they are no more effective than hyaluronic acid and presumably placebo.

ACUTE MUSCULOSKELETAL INJURY PAIN

The first study included 119 patients presenting to an emergency department with acute musculoskeletal injury. Patients were randomized to receive 1,000 mg of acetaminophen plus placebo or 1,000 mg of acetaminophen plus 400 mg of ibuprofen plus 60 mg of codeine.4 Pain at rest was reduced similarly in both groups at one and two hours. Pain with activity was reduced slightly more with the combination therapy, but this difference was not considered clinically important, and adverse events were three times more common in the combination therapy group.

PLATELET-RICH PLASMA INJECTIONS

The next two studies evaluated the effectiveness of platelet-rich plasma injections. The first was a meta-analysis of five studies evaluating this therapy in a total of 214 patients with chronic rotator cuff disease.5 The control groups received a variety of interventions, such as saline or corticosteroid injection, dry needling, or exercise therapy. At six to 12 months of follow-up, there was no difference between the intervention group and the control groups in pain, disability, or range of motion. In the studies comparing platelet-rich plasma injections with exercise, the exercise group had better outcomes.

The second POEM was the five-year follow-up of a study that randomized 192 patients with severe knee osteoarthritis to receive injections of platelet-rich plasma or hyaluronic acid.6 Because previous systematic reviews of adequately controlled and masked trials of hyaluronic acid found no significant benefit vs. placebo,7,8 this POEM could be considered similar to a placebo-controlled trial. After five years, about 86% of patients remained in the study, and pain and functional scores were similar between groups. Therefore, neither platelet-rich plasma nor hyaluronic acid is recommended over placebo for the treatment of knee osteoarthritis.

Respiratory Disease

Four POEMs focus on respiratory disease (Table 2).913

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