Annually for 23 years, a team of clinicians has systematically reviewed English-language medical journals to identify the research most likely to change and improve primary care. The team includes experts in family medicine, pharmacology, hospital medicine, and women’s health.^1,2

The goal of this process is to identify POEMs (patient-oriented evidence that matters). A POEM must report at least one patient-oriented outcome, such as improvement in symptoms, morbidity, or mortality. It should also be free of important methodologic bias, making the results valid and trustworthy. Finally, if the results were applied in practice, some physicians would change what they do by adopting a new practice or discontinuing an old one shown to be ineffective or harmful. Adopting POEMs in clinical practice should improve patient outcomes. Of more than 20,000 research studies published in 2021 in the journals reviewed by the POEMs team, only 260 met criteria for validity, relevance, and practice change. These POEMs are emailed daily to subscribers of Essential Evidence Plus (Wiley-Blackwell, Inc.).

The Canadian Medical Association purchases a POEMs subscription for its members, many of whom receive the daily POEM. As these physicians read each POEM, they can rate it using a validated questionnaire. This process is called the Information Assessment Method (https://www.mcgill.ca/iam). POEM ratings address the domains of clinical relevance, cognitive impact, use in practice, and expected health benefits if that POEM is applied to a specific patient.^2,3 In 2021, each of the 260 daily POEMs were rated by an average of 1,189 physicians.

In this article, the 11th installment of our annual series (https://www.aafp.org/pubs/afp/content/top-poems.html), we present the 20 most clinically relevant POEMs of 2021 as determined by Canadian Medical Association members. Looking beyond COVID-19, our patients continue to face the usual (and unusual) health problems of everyday life. Thus, we summarize the clinical questions and bottom-line answers for research studies about a variety of topics that were identified as top 20 POEMs, followed by a brief discussion. This set of 20 POEMs includes the most relevant practice guidelines of the year. The full POEMs are available online at https://www.aafp.org/pubs/afp/content/top-poems/2021.html.

The five most highly rated POEMs in 2021, and eight of the top 15, were about the COVID-19 vaccines and their effectiveness in different populations. Because of the emergence of variants and widespread endorsement of the vaccine by family physicians, these POEMs are not as likely to lead to practice changes as they were when originally published. One additional COVID-19 POEM reported the incidence of myocarditis following vaccination with the Pfizer BioNTech and Moderna mRNA vaccines in U.S. military personnel. The incidence of approximately 4 more cases than expected per 100,000 patients is significantly lower than the more than 300 per 100,000 patients seen among those with SARS-CoV-2 infection.⁴ The rest of this article includes POEMs not related to the COVID-19 pandemic.

Type 2 Diabetes Mellitus

The first three POEMs in this category are about the management of type 2 diabetes (Table 1).^5–8 The first study identified 2,482 adults with a mean age of 75 years who had prediabetes (defined as an A1C level between 5.7% and 6.4%, a fasting glucose level between 100 and 125 mg per dL [5.55 and 6.94 mmol per L], or both).⁵ Over an average of 6.5 years, only 8% to 9% of patients progressed to diabetes, many regressed to normoglycemia, and the remainder stayed at prediabetic levels. These results will help reassure physicians and avoid overtreatment of older patients with prediabetes. Of note, the U.S. Preventive Services Task Force does not recommend screening for prediabetes or type 2 diabetes beyond 70 years of age.⁹

A study in the United Kingdom identified 6,288 people 70 years and older with type 2 diabetes and three consecutive A1C measurements of less than 7%.⁶ Approximately 90% were taking a sulfonylurea. Compared with a similar group of people with type 2 diabetes who did not have A1C levels of less than 7% and were not taking a sulfonylurea, those with tight control were 2.5 times more likely to be hospitalized for severe hypoglycemia, with a 1 in 7 risk of hospitalization over 10 years. Use of a sulfonylurea or insulin was associated with severe hypoglycemia and death. A more relaxed A1C target of 7.0% to 8.0% is more appropriate, especially for older patients, and sulfonylureas should be used with caution.