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Am Fam Physician. 2023;107(4):406-414

This clinical content conforms to AAFP criteria for CME.

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

This article summarizes the top 20 research studies of 2022 identified as POEMs (patient-oriented evidence that matters), excluding COVID-19. Statins for primary prevention of cardiovascular disease produce only a small absolute reduction in a person's likelihood of dying (0.6%), having a myocardial infarction (0.7%), or having a stroke (0.3%) over three to six years. Supplemental vitamin D does not reduce the risk of a fragility fracture, even in people with low baseline vitamin D levels or a previous fracture. Selective serotonin reuptake inhibitors are preferred medical therapy for panic disorder, and patients who discontinue antidepressants are more likely to relapse (number needed to harm = 6) compared with those who continue. Combination therapy using a selective serotonin reuptake inhibitor, serotonin-norepinephrine reuptake inhibitor, or tricyclic antidepressant with mirtazapine or trazodone is more effective than monotherapy for first-line treatment of acute severe depression and when monotherapy fails. Using hypnotic agents for insomnia in adults comes with a significant trade-off between effectiveness and tolerability. In patients with moderate to severe asthma, using a combination of albuterol and glucocorticoid inhalers as rescue therapy reduces exacerbations and need for systemic steroids. Observational research shows an increased risk of gastric cancer in patients taking proton pump inhibitors (number needed to harm = 1,191 over 10 years). The American College of Gastroenterology updated its guideline for gastroesophageal reflux disease, and a new guideline provides sound advice for the evaluation and management of irritable bowel syndrome. Adults older than 60 years with prediabetes are more likely to become normoglycemic than to develop diabetes mellitus or die. Treatment of prediabetes via intensive lifestyle intervention or metformin has no impact on long-term cardiovascular outcomes. Persons with painful diabetic peripheral neuropathy have similar degrees of improvement with monotherapy using amitriptyline, duloxetine, or pregabalin and greater improvement with combination therapy. When communicating with patients about disease risk, most patients prefer numbers over words because people overestimate word-based probabilities. In terms of drug therapy, the duration of an initial varenicline prescription should be 12 weeks. Many drugs can interact with cannabidiol. No important difference was found among ibuprofen, ketorolac, and diclofenac for treatment of acute nonradicular low back pain in adults.

For the past 24 years, a team of six clinicians has systematically reviewed more than 100 medical journals to find the research most likely to change and improve primary care practice. 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 applied in practice, the results would change what some physicians do by adopting a new practice or discontinuing an old one shown to be ineffective or harmful. Of more than 20,000 research studies published in 2022 in the journals reviewed by the POEMs team, 253 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, and thousands of its members receive the daily POEM. These physicians can rate each one using a validated questionnaire.3 This process is called the Information Assessment Method ( POEM ratings address the domains of clinical relevance, cognitive impact, use in practice, and expected health benefits. In 2022, each of the 253 daily POEMs were rated by an average of 1,087 physicians. New for 2022, readers of the daily POEM saw an “overuse alert” for POEMs that align with a Choosing Wisely recommendation.4

In this article, the 12th installment of our annual series (, we summarize the 20 most clinically relevant POEMs of 2022 as determined by Canadian Medical Association members. Although some of the most highly rated POEMs addressed COVID-19, rapid changes in management as the pandemic has evolved make many of them less relevant in 2023. Therefore, we briefly summarize these COVID-19 POEMs, as well as highly rated practice guidelines, separately. The full POEMs discussed in this review are available at

Preventive Health Care

The first two POEMs relate to preventive medicine (Table 1).5,6 Many patients take statins to reduce cardiovascular events. But how large is the benefit? A meta-analysis identified 19 studies that randomized 132,763 patients to statin therapy or placebo.5 Studies were typically three to six years in duration, and statins reduced the risk of overall death by 0.8%, myocardial infarction by 1.3%, and stroke by 0.4%. When statins were used as primary prevention, the reductions were smaller: 0.6% fewer deaths, 0.7% fewer myocardial infarctions, and 0.3% fewer strokes, for an overall number needed to treat of 63 to prevent one event over three to six years. The 95% CI around all-cause mortality alone was 88 to 250 over several years of treatment as primary prevention. Not bad, but this is probably a higher number needed to treat than most of our patients believe.

Clinical questionBottom-line answer
1. What is the impact of LDL cholesterol reduction on the individual risks of overall mortality, myocardial infarction, and stroke?5 Statins for primary prevention produce modest benefit.
Reducing LDL cholesterol levels with statins provides only a small absolute reduction in the person's overall likelihood of dying (0.8% reduction), having a myocardial infarction (1.3%), or having a stroke (0.4%) over three to six years. Too often we are given relative risk reductions or a bundling together of these outcomes with other lesser outcomes, which leads to an inflated sense of importance attributed to cholesterol treatment. In addition, the authors also found a small and inconsistent relationship between more intensive lowering of LDL cholesterol and these outcomes, which is contrary to what many (U.S.) guidelines would have us believe.
2. Does supplemental vitamin D reduce the risk of fracture in older adults?6 Vitamin D supplementation does not reduce fracture risk.
Vitamin D level is a very good marker of ill health, but a terrible treatment target. This large study showed definitively that supplemental vitamin D does not reduce the risk of fracture, even in people with low baseline vitamin D levels or a previous fracture.

Screening for low vitamin D levels and recommending replacement in those who are deficient have become popular, although the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend screening in asymptomatic individuals.7 A trial randomized 25,871 men 50 years or older and women 55 years or older to receive 2,000 IU of vitamin D or placebo daily for a median of five years.6 There was no difference between groups in any type of fracture, even in patients with low baseline vitamin D levels (hazard ratio = 1.04; 95% CI, 0.80 to 1.36) or a previous fracture.

Behavioral Health

The first POEM in this group provides insight into what happens when a patient discontinues an antidepressant8 (Table 2813). The study included primary care patients with at least two episodes of depression who had been taking an antidepressant for at least two years.8 Patients were randomized to continue the medication or taper it over two months to placebo. After one year, the likelihood of relapse was significantly higher in the discontinuation group (56% vs. 39%; hazard ratio = 2.1; 95% CI, 1.6 to 2.7). Symptoms in the discontinuation group were also more severe.

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