Since 2005, members of the Canadian Medical Association (CMA) have been rating daily synopses of research studies or clinical practice guidelines, called POEMs (Patient-Oriented Evidence that Matters), which raise awareness of the most relevant research studies and guidelines for improving clinical practice.
Additionally, POEMs can raise awareness of the Choosing Wisely Canada (CWC) campaign.1,2 In 2022, readers of the daily POEMs saw something new: specific recommendations from CWC were aligned to 18 POEMs.3 Selected POEMs included alerts about overuse and links to relevant CWC resources. Table 1 presents these POEMs and their associated tool kits.3-20
POEMs of 2022 aligned with CWC recommendations
In this article, we present the top 10 POEMs of 2022 for choosing wisely in clinical practice according to CMA members.
How we selected these POEMs
In 2022, 253 POEMs were delivered to CMA members by e-mail. Each daily POEM is opened by about 10,000 CMA members and rated by about 1000. Ratings are made using a validated questionnaire.21 For each POEM, we used all ratings to obtain a count of the number of CMA members who indicated “this POEM will help to avoid unnecessary treatment, diagnostic procedures, preventive interventions, or a referral for this patient.” We counted this specific item on the rating questionnaire because of its direct mention of reducing overdiagnosis or overtreatment—a health benefit associated with the CWC campaign. Table 2 provides a concise list of the top 10 POEMs and additional information about each POEM.3,22-31 Four of these POEMs were aligned to a CWC recommendation.
Summary of the top 10 POEMs of 2022 for choosing wisely in medicine: Four of the top 10 POEMs in 2022 were aligned with a Choosing Wisely Canada recommendation.
Top 10 POEMs of 2022 for choosing wisely
No benefit of varenicline after 12 weeks for smoking cessation. A randomized controlled trial addressed the following question: Is there benefit to extending varenicline treatment beyond 12 weeks to improve smoking cessation? At week 52 of follow-up, there was no difference in smoking cessation rates between those randomized to receive varenicline for 12 weeks and those randomized to 24 weeks.22 Unless the patient asks for a longer course of treatment, the initial prescription should specify a duration of 12 weeks.
For children with community-acquired pneumonia, low-dose amoxicillin for 3 days is noninferior to high-dose amoxicillin for 7 days. A randomized controlled trial investigating the optimal dosage of amoxicillin for managing community-acquired pneumonia (clinically diagnosed based on international guidelines)32 in children 6 months or older found, at day 28, no difference in the need for retreatment for respiratory infection between the 3-day amoxicillin treatment and the 7-day amoxicillin treatment.23 One CMA member commented, “This type of research is important in the context of the need for smarter antibiotic stewardship.”
Treatment of prediabetes with metformin or intensive lifestyle therapy for at least 3 years has no long-term benefits. This POEM reports long-term cardiovascular and mortality outcomes for each group that was randomized in the Diabetes Prevention Program trial.24 Overall, in patients with prediabetes (ie, impaired glucose tolerance, fasting plasma glucose levels from 5.27 to 6.94 mmol/L, body mass index ≥24 kg/m2), neither an intensive lifestyle intervention nor metformin treatment had any impact on the long-term risk of cardiovascular outcomes.
Persons older than 60 years with prediabetes are more likely to become normoglycemic than to develop diabetes or die. The natural history of prediabetes in adults older than 60 years was studied in a cohort of more than 2000 adults in England who did not have diabetes at baseline. The average age of participants was 70.6 years and 55% were women. During 8 years of follow-up, older persons with prediabetes were more likely to become normoglycemic than to develop diabetes or to die.25 One CMA member commented, “It’s time to retire the term prediabetes when talking with older people.”
Intensive urate lowering for erosive gout is difficult to achieve and does not improve outcomes. This POEM reports on a trial that asked whether intensive urate lowering improves outcomes in persons with erosive gout, which found that intensive urate lowering is difficult to achieve, uses many medications, and does not improve outcomes meaningful to patients such as pain or quality of life.26
Proton pump inhibitor (PPI) use is associated with an increased risk of gastric cancer. An observational study asked the following question: Is there an association between gastric cancer and the use of PPIs? The study found that there is a small increase in the risk of gastric cancer for patients taking a PPI (number needed to harm=1191 over 10 years).27 However, it is important to remember that association is not causation. Yet, physicians initiating antacid therapy should begin with histamine-2 receptor antagonist therapy, and if prescribing a PPI should use the lowest dose and duration possible. Choosing Wisely Canada has a tool kit for deprescribing PPIs.16
The presence of white blood cells does not equate to the presence of bacterial cells in the urine of hospitalized patients. This POEM about a cohort study28 aligns with a CWC recommendation from the Canadian Nurses Association18: Do not do a urine dip or send urine specimens for culture unless urinary tract symptoms are present. Furthermore, in the outpatient setting, in women with typical symptoms there are few reasons to send urine for any testing.33
Three clinical practice guidelines made it into the top 10 POEMs list.
American College of Gastroenterology guideline for diagnosing and managing gastroesophageal reflux disease (GERD). This guideline asks the following question: How should clinicians evaluate and manage persons with suspected GERD? The panel recognized that some patients require long-term PPI therapy. Studies reporting an association between the long-term use of PPIs and harms such as gastric cancer do not establish a cause-and-effect relationship.27 Yet, clinicians should attempt to discontinue PPIs after a successful 8-week trial in persons with classic GERD symptoms and no symptoms that alarm.29 A tool kit from CWC has information on how to deprescribe PPIs.16
British Society of Gastroenterology guidelines for the management of irritable bowel syndrome. Informed by systematic and comprehensive reviews of the literature, a multidisciplinary panel issued many recommendations regarding the diagnostic evaluation of those with irritable bowel syndrome, which is defined by at least 6 months of abdominal pain or discomfort, in association with altered bowel habits.30 For example, colonoscopy is recommended only for patients with signs and symptoms that alarm or for those at risk of microscopic colitis. Recommendations for first- and second-line treatments are also summarized in the POEM.
The US Preventive Services Task Force recommends against initiating acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease in adults 60 years or older. In its 2022 guideline update, the US Preventive Services Task Force no longer recommends ASA use for primary prevention of cardiovascular disease in adults 60 years or older. For those already taking or choosing to start taking ASA, the task force recommends stopping ASA use at approximately 75 years of age. Considerations for younger persons at particularly high risk differ.31
Notes
Choosing Wisely Canada is a campaign designed to help clinicians and patients engage in conversations about unnecessary tests, treatments, and procedures and to help physicians and patients make smart and effective choices to ensure high-quality care is provided. To date there have been 13 family medicine recommendations, but many of the recommendations from other specialties are relevant to family medicine. Articles produced by Choosing Wisely Canada in Canadian Family Physician are on topics related to family practice where tools and strategies have been used to implement one of the recommendations and to engage in shared decision making with patients. If you are a primary care provider or trainee who has used Choosing Wisely recommendations or tools in your practice and you would like to share your experience, please contact us at info{at}choosingwiselycanada.org.
Footnotes
Competing interests
None declared
This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to https://www.cfp.ca and click on the Mainpro+ link.
Cet article se trouve aussi en français à la page 174.
- Copyright © 2023 the College of Family Physicians of Canada
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