Article Figures & Data
Tables
POEM TITLE RECOMMENDATION (SOURCE) TOOL KIT Hypnotic agents are effective for insomnia but at the expense of adverse effects3 Do not use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium (Canadian Geriatrics Society)4 CWC’s primary care5 and hospital6 tool kits indicate how to reduce unnecessary benzodiazepine use in older adults NICE guidance: type 2 diabetes (2022)3 Avoid using medications known to cause hypoglycemia to achieve hemoglobin A1c <7.5% in many adults aged 65 and older; moderate control is generally better (Canadian Geriatrics Society)4 None Do not recommend routine or multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia (Canadian Society of Endocrinology and Metabolism)7 Postoperative opioids are no better for pain relief and cause more adverse effects than nonopioids3 Prolonged use of opioid analgesia beyond the immediate postoperative period or other acute pain episode is not recommended (Canadian Association of General Surgeons)8 Opioid Wisely CWC campaign provides recommendations and patient resources for reducing unnecessary opioid prescribing9 Comparable postoperative pain relief for opioid- and nonopioid-based regimens following ACL reconstruction3 Do not initiate opioids long term for chronic pain until there has been a trial of available nonpharmacologic treatments and adequate trials of nonopioid medications10 None Only some musculoskeletal conditions benefit from surgery3 Do not use arthroscopic debridement as a primary treatment in the management of osteoarthritis of the knee (Canadian Orthopaedic Association; Canadian Arthroplasty Society; Arthroscopy Association of Canada)11 None Do not perform fusion surgery to treat patients with mechanical axial low back pain from multilevel spine degeneration in the absence of: (a) leg pain with or without neurologic symptoms and/or signs of concordant neurologic compression, and (b) structural pathology such as spondylolisthesis or deformity (Canadian Spine Society)12 Tight control associated with more frequent and persistent hypoglycemia in elderly persons with diabetes mellitus3 Avoid using medications known to cause hypoglycemia to achieve hemoglobin A1c <7.5% in many adults aged 65 and older; moderate control is generally better (Canadian Geriatrics Society)4 None Amoxicillin for children with CAP: low dose for 3 days is noninferior to high dose for 7 days3 These 3 POEMs align with CWC’s Using Antibiotics Wisely campaign13 CWC Cold Standard tool kit provides tools for reducing unnecessary antibiotics14 Comparable outcomes with 5 days and 10 days of antibiotics in children with CAP3 Point-of-care testing for respiratory pathogens does not reduce antibiotic use or improve outcomes3 Proton pump inhibitor use associated with an increased risk of gastric cancer3 These 2 POEMs align with the following CWC recommendation: Do not maintain long-term PPI therapy for gastrointestinal symptoms without an attempt to stop or reduce PPI at least once per year in most patients15 CWC’s tool kit provides tools for deprescribing PPIs16 American College of Gastroenterology guideline for diagnosing and managing GERD3 Screening colonoscopies are overused3 Avoid colorectal cancer screening tests in asymptomatic patients with a life expectancy of less than 10 years and with no personal or family history of colorectal neoplasia (Canadian Association of General Surgeons)8 None Urine collection devices do not reduce contamination in women with suspected urinary tract infections3 Do not use a bag for collection of urine cultures to diagnose urinary tract infections (Association of Medical Microbiology and Infectious Disease Canada)17 None White blood cells do not equate to bacterial cells in the urine of hospitalized patients3 Do not do a urine dip test or send urine specimens for culture unless urinary tract symptoms are present (Canadian Nurses Association and Infection Prevention and Control Canada)18 None Antibiotics for asymptomatic bacteriuria in residents of aged care facilities: bacteriologic, but not clinical, cure; more adverse events3 Linked to this POEM are 9 recommendations to reduce unnecessary antibiotic use for asymptomatic bacteriuria13 Using Antibiotics Wisely in long-term care CWC recommendation provides information on reducing unnecessary antibiotic use for asymptomatic bacteriuria13 A high-sensitivity troponin T level less than 6 ng/L is very good at ruling out myocardial infarction or death in the next 30 days3 Do not test for myoglobin or creatine kinase MB in the diagnosis of acute myocardial infarction. Instead, use troponin I or T (Canadian Cardiovascular Society)19 None Neither vitamin D nor omega-3 fatty acid supplementation reduce the risk of frailty3 Do not routinely measure vitamin D in low-risk adults (College of Family Physicians of Canada)10 None NICE guidelines on treatment of depression3 Do not routinely use antidepressants as first-line treatment for mild or subsyndromal depressive symptoms in adults (Canadian Academy of Child and Adolescent Psychiatry; Canadian Academy of Geriatric Psychiatry; Canadian Psychiatric Association)20 None ACL—anterior cruciate ligament, CAP—community-acquired pneumonia, CWC—Choosing Wisely Canada, GERD—gastroesophageal reflux disease, NICE—National Institute for Health and Care Excellence, POEM—Patient-Oriented Evidence that Matters, PPI—proton pump inhibitor.
- Table 2.
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.
POEM TITLE ADDITIONAL INFORMATION No benefit of varenicline therapy after 12 weeks or when combined with nicotine replacement therapy for smoking cessation For increasing smoking cessation rates, this study found no additional benefit with varenicline plus nicotine replacement therapy vs varenicline monotherapy, or with varenicline treatment for 24 weeks vs 12 weeks. These results were not affected by sex, race, treatment site, or level of tobacco dependence22 Amoxicillin for children with CAP: low dose for 3 days is noninferior to high dose for 7 days3 Regarding the need for retreatment of CAP in children discharged from an emergency department or inpatient setting within 48 hours, this study found that low-dose outpatient oral amoxicillin was noninferior to the high-dose version and that taking the medication for 3 days was noninferior to taking it for 7 days23 Treatment of prediabetes with metformin or intensive lifestyle therapy for at least 3 years has no long-term benefits In patients with prediabetes, neither an intensive lifestyle intervention nor metformin had any impact on the long-term risk of cardiovascular outcomes24 Persons older than 60 years with prediabetes are more likely to become normoglycemic than to develop diabetes or die In a cohort study of more than 2000 adults (average age 70.6 years), those with prediabetes were more likely to become normoglycemic than to develop diabetes or die during 8 years of follow-up25 Intensive urate lowering for erosive gout is difficult to achieve and does not improve outcomes In adults with erosive gout, intensive urate lowering is difficult to achieve, requires many medications, and does not improve outcomes26 Proton pump inhibitor use associated with an increased risk of gastric cancer3 This is the strongest evidence to date that there is a small but clinically significant increase in the risk of gastric cancer for patients taking a PPI (NNH=1191 over 10 years). Physicians initiating antacid therapy for patients should begin by prescribing an H2RA, and if prescribing a PPI, should use the lowest dose and duration possible27 White blood cells do not equate to bacterial cells in the urine of hospitalized patients3 Approximately 1 in 7 women and 1 in 38 men have pyuria without bacterial infection. Pyuria, identified in this study by microscopy, is not a good indicator of bacteria in hospitalized patients with suspected urinary tract infection; even at a cutoff of 25 cells per high-power field, only about half of patients will have positive culture results28 American College of Gastroenterology guideline for diagnosing and managing GERD3 The American College of Gastroenterology has updated its guideline for the diagnosis and management of GERD. The paper has several useful tables and algorithms that may be of use to primary care clinicians29 British Society of Gastroenterology guidelines for the management of IBS This high-quality, evidence-based guideline provides good advice for the evaluation and management of IBS in primary care30 USPSTF 2022 guideline update recommends against initiating ASA for primary prevention of CVD in adults 60 years or older The USPSTF recommends against initiating low-dose ASA (81 mg/d) for the primary prevention of CVD in adults 60 years or older (GRADE D recommendation). The task force recommends using shared decision making when initiating low-dose ASA for the primary prevention of CVD in adults 40 to 59 years with a 10% or greater risk of CVD and without an increased risk of bleeding (GRADE C recommendation). Risk factors for bleeding include older age, history of peptic ulcer disease, alcoholism, liver disease, long-term nonsteroidal anti-inflammatory drug or steroid use, and anticoagulant therapy31 ASA—acetylsalicylic acid; CAP—community-acquired pneumonia; CVD—cardiovascular disease; GERD—gastroesophageal reflux disease; GRADE—Grading of Recommendations Assessment, Development and Evaluation; H2RA—histamine-2 receptor antagonist; IBS—irritable bowel syndrome; NNH—number needed to harm; POEM—Patient-Oriented Evidence that Matters; PPI—proton pump inhibitor; USPSTF—US Preventive Services Task Force.
In this issue
Jump to section
Related Articles
Cited By...
- No citing articles found.