Top POEMs of 2018 Consistent with the Principles of the Choosing

290 American Family Physician www.aafp.org/afp Volume 100, Number 5

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September 1, 2019

A POEM (patient-oriented evidence that matters) is a syn-

opsis of a research study that reports patient-oriented out-

comes, such as improvement in symptoms, quality of life, or

mortality; is free of important methodologic bias; and rec-

ommends a change in practice for many physicians. In this

article, we discuss the POEMs of 2018 that were most con-

sistent with principles of the Choosing Wisely campaign,

an international eort to reduce unnecessary medical tests,

treatments, and procedures. Unlike articles where experts

choose the top research papers of the year, our crowdsourc-

ing method allows us to identify new studies about clini-

cal actions most consistent with Choosing Wisely, from the

perspective of the physician in everyday practice.

1,2

In brief, our crowdsourcing method to identify the top

POEMs of 2018 consistent with Choosing Wisely is based

on physician ratings of the daily POEMs delivered in the

context of a continuing medical education program. On

average, we received 1,574 physician ratings for each of the

255 unique POEMs in 2018 delivered to members of the

Canadian Medical Association. Using these ratings, we

compiled a list of top POEMs, which we previously sum-

marized in American Family Physician.

In this article, we

now present the top POEMs of 2018 whose ndings were

judged to help reduce overdiagnosis or overtreatment in

clinical practice and are thus consistent with the principles

of the Choosing Wisely campaign.

Note that 13 of the top POEMs of 2018 also ranked at the

top for Choosing Wisely. We do not rediscuss these POEMs

in this article, but they are summarized in eTable A. In

addition, all articles in the top POEMs series are available at

https:// www.aafp.org/afp/toppoems.

Musculoskeletal Conditions

e rst group of POEMs focuses on the treatment of

chronic subacromial shoulder pain and lower back pain

(Table 1

4-6

CHRONIC SHOULDER PAIN

Subacromial shoulder pain, located near the top and lateral

side of the shoulder, is common in middle age. Worldwide,

Top POEMs of 2018 Consistent

with the Principles of the

Choosing Wisely Campaign

Roland Grad, MD, MSc, McGill University, Montreal, Quebec, Canada

Mark H. Ebell, MD, MS, University of Georgia, Athens, Georgia

Additional content at https:// www.aafp.org/afp/2019/0901/

p290.html.

POEMs are provided by Essential Evidence Plus, a point-

of-care clinical decision support system published by

Wiley-Blackwell, Inc. For more information, visit http://

www.essentialevidenceplus.com.

The full text of the POEMs discussed in this article is avail-

able at https:// www.aafp.org/afp/poems-cw-2018.

CME

This clinical content conforms to AAFP criteria for

continuing medical education (CME). See CME Quiz on

page 271.

Author disclosure: No relevant ﬁnancial aliations.

In this article, we discuss the POEMs (patient-oriented evidence that matters) of 2018 judged to be most consistent with

the principles of the Choosing Wisely campaign. We selected these POEMs through a crowdsourcing strategy of the daily

POEMs information service for Canadian Medical Association’s physician members. We present recommendations from these

top POEMs of primary research or meta-analysis that identify interventions to consider avoiding in practice. The recom-

mendations cover musculoskeletal conditions (e.g., avoid decompression surgery for treatment of subacromial shoulder

pain), respiratory disease (in mild asthma, do not routinely prescribe a long-term daily inhaled steroid over the as-needed

use of budesonide/formoterol), infections (e.g., in children with acute respiratory tract infection, do not routinely prescribe

broad-spectrum antibiotics over narrow-spectrum antibiotics), and cardiovascular disease (e.g., avoid blanket testing of car-

diac troponin in patients with a low pretest likelihood of myocardial infarction). 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 their patients

2019 American Academy of Family Physicians.)

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Volume 100, Number 5 www.aafp.org/afp American Family Physician 291

arthroscopic subacromial decompres-

sion is the most common shoulder

surgery. In 2018, two well-conducted

randomized controlled trials summa-

rized as POEMs reported no symptom

benet from decompression surgery

compared with physical therapy or

noncorrective surgery.

e Finnish Subacromial Impinge-

ment Arthroscopy Controlled Trial

enrolled adults with an impingement

syndrome and no evidence of a rotator

cu tear on magnetic resonance imag-

ing.

Participants were enrolled if they

had not responded to at least three

months of conventional treatment, such

as steroid injection. ey were random-

ized to physical therapy or surgery, with

the surgical group further randomized

in the operating room to subacromial

decompression or diagnostic arthroscopy with no decom-

pression. No dierence in pain or function scores was noted

aer up to two years. However, patients in all three groups

reported a large decrease in pain over time. A video summa-

rizing the ndings of the trial is available at https:// www.bmj.

com/content/362/bmj.k2860/rr-9.

e Can Shoulder Arthroscopy Work study also failed to

demonstrate a benet of arthroscopic subacromial decom-

pression over a placebo surgery.

Both trials failed to iden-

tify a subgroup of patients with subacromial pain who

beneted enough from subacromial decompression to jus-

tify the harms. Consequently, in 2019, a panel assembled

by the British Medical Journal made a strong recommen-

dation against surgery, concluding that almost all informed

patients would choose to avoid surgery because surgery is

burdensome, there is no benet, and there are harms.

CHRONIC LOWER BACK PAIN

For many years, amitriptyline has been prescribed for

dicult-to-treat painful conditions such as chronic lower

back pain. In a randomized clinical trial of 146 participants

with chronic lower back pain, amitriptyline (25 mg per day)

was compared with benztropine (1 mg per day), a similar

mouth-drying placebo.

No improvement in pain, disability,

or work outcomes was demonstrated at six months. How-

ever, there was a reduction in disability at three months,

and minimal adverse events were reported in the treatment

group. For Choosing Wisely, it may still be worth a three-

month trial of low-dose amitriptyline for patients living with

chronic back pain, given the limited pharmacologic alterna-

tives, namely cannabidiol, opioids, or gabapentinoids.

Respiratory Disease

In adults with uncontrolled mild asthma, two POEMs

in 2018 addressed newer strategies to control symptoms

or prevent severe exacerbations using a combination of a

steroid and a long-acting beta agonist in a single inhaler

(Table 2

8,9

e SYGMA (Symbicort Given as Needed in Mild

Asthma) 1 trial found that the as-needed use of an inhaled

steroid plus a long-acting beta agonist is almost as eective

in preventing asthma exacerbations as daily maintenance

steroid therapy, and at one-h of the steroid dose.

Use of

an as-needed inhaled steroid plus a long-acting beta agonist

(budesonide/formoterol [Symbicort], 160 mcg/4.5 mcg)

or a regular daily inhaled steroid (budesonide [Rhino-

cort], 160 mcg twice per day) prevented asthma exacer-

bations, compared with as-needed inhaled terbutaline.

e SYGMA 2 trial found no dierence for the outcome

of severe asthma exacerbation over one year between the

as-needed use of budesonide/formoterol, 200 mcg/6 mcg,

and the daily use of budesonide, 200 mcg, plus as-needed

use of terbutaline.

ese ndings are helpful for Choosing Wisely. First,

unless your patient has very mild and intermittent asthma,

current asthma guidelines recommend against use of a

short-acting beta agonist alone.

Second, some adults

with mild asthma prefer to avoid taking inhaled steroids

on a long-term daily basis. erefore, a process of shared

decision-making for inhaled steroid use is appropriate for

patients with mild asthma, given the options of daily inhaled

budesonide or intermittent budesonide/formoterol in a sin-

gle inhaler, to reduce the cumulative steroid burden. A note

TABLE 1

Musculoskeletal Conditions

POEM title

Clinical actions to consider for Choosing

Wisely

Decompression surgery no more

eective than exercise for shoulder

impingement syndrome

Surgery = no surgery for patients with

subacromial shoulder pain (CSAW)

In patients with chronic subacromial

shoulder pain and no history of trauma,

do not refer for surgical decompression

of the subacromial space.

Amitriptyline ineective for chronic

back pain

In patients with chronic lower back

pain, do not use amitriptyline for long-

term relief, although there may be

some short-term beneﬁt.

CSAW = Can Shoulder Arthroscopy Work study; POEM = patient-oriented evidence that

matters.

Information from references 4-6.

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292 American Family Physician www.aafp.org/afp Volume 100, Number 5

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September 1, 2019

of caution: other combination long-acting beta

agonist/steroid inhalers have not been similarly

evaluated.

Infections

Two POEMs about infections (or their sequelae)

identied clinical actions that physicians should

consider avoiding in practice (Table 3

11,12

ACUTE RESPIRATORY TRACT INFECTIONS

IN CHILDREN

It can be tempting to prescribe an empiric

broad-spectrum antibiotic for children with

acute respiratory tract infections in the out-

patient setting. e authors of a well-designed

cohort study of 30,159 children six months to 12

years of age evaluated whether broad-spectrum

antibiotics are preferred over narrow-spectrum

antibiotics for acute respiratory tract infections,

including otitis media, streptococcal pharyngi-

tis, and sinusitis. ere was no dierence in the

rate of treatment failure across the groups, but

more adverse events were reported by the par-

ents of those taking broad-spectrum antibiotics.

Adverse events included diarrhea, candidia-

sis, rash, other allergic reactions, and vomiting.

erefore, when antibiotics are indicated in

children with acute respiratory tract infections,

narrow-spectrum antibiotics are preferred.

CHRONIC SINUSITIS

Patients with chronic sinusitis have two or more

of the following symptoms: mucopurulent drain-

age, nasal obstruction, facial pain, decreased

sense of smell. First-line treatment options for

chronic sinusitis are intranasal steroids and intranasal

saline irrigation, usually in combination.

For patients

who hesitate to use intranasal steroids, a small trial com-

paring saline irrigation with placebo or an intranasal ste-

roid showed a benet of large-volume saline irrigation alone

over 30 days in patients with chronic sinusitis of at least 12

weeks duration.

Physicians who wish to continue prescrib-

ing intranasal steroids will not nd reason to stop based on

this trial, because a clinically important benet was seen in

more participants in the saline plus steroid group (79% vs.

59%; not statistically dierent, perhaps because of the size

of the study sample).

Cardiovascular Disease

Two POEMs about cardiovascular disease deserve attention

by the Choosing Wisely campaign (Table 4

14,15

DEFINITION OF HYPERTENSION

Is there a clear line for when hypertension should be diag-

nosed and treatment initiated? In a previous issue of Amer-

ican Family Physician, we briey addressed the treatment

component of this question based on the ndings of a 2018

systematic review and meta-analysis.

3,16

In a commentary

on redening disease, a checklist of criteria was applied

for comparing the 2017 American College of Cardiology/

American Heart Association guidelines recommending a

lower blood pressure target for many patients with previ-

ous targets.

is helped the authors evaluate the risk of

overdiagnosis and overtreatment arising from a lower treat-

ment threshold. eir ndings suggest that using a lower

threshold might benet some patients at high risk of car-

diovascular disease but harm patients at low risk. Taking a

Choosing Wisely approach requires calculating a patient’s

TABLE 3

Infections

POEM title

Clinical actions to consider

for Choosing Wisely

Broad-spectrum antibiotics

increase adverse events in

children with acute respira-

tory infections, with no added

beneﬁt over narrow-spectrum

antibiotics

In children with an acute respiratory

infection, including otitis media,

streptococcal pharyngitis, and

sinusitis, do not routinely prescribe

broad-spectrum antibiotics over

narrow-spectrum antibiotics.

Chronic sinusitis: saline

irrigation helps somewhat;

intranasal steroid doesn’t sub-

stantially add more beneﬁt

In chronic sinusitis, saline irrigation

can sometimes be good enough

for symptom control.

POEM = patient-oriented evidence that matters.

Information from references 11 and 12.

TABLE 2

Respiratory Disease

POEM title Clinical actions to consider for Choosing Wisely

Steroid + LABA simi-

lar to daily steroid for

preventing exacerba-

tions in mild asthma

(SYGMA 1)

In adults with mild asthma, do not rou-

tinely prescribe a long-term daily inhaled

steroid over as-needed budesonide/

formoterol (Symbicort) without clarifying

patient preference in a process of shared

decision-making.

As-needed use of

budesonide plus

formoterol as good

as daily use of steroid

(SYGMA 2)

In adults with mild asthma, do not recom-

mend a long-term daily inhaled steroid

over as needed budesonide/formoterol for

prevention of severe exacerbations.

LABA = long-acting beta agonist; POEM = patient-oriented evidence that mat-

ters; SYGMA = Symbicort Given as Needed in Mild Asthma trial.

Information from references 8 and 9.

September 1, 2019

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Volume 100, Number 5 www.aafp.org/afp American Family Physician 293

baseline risk of cardiovascular disease and using this risk

in the context of a conversation about blood pressure goals,

considering the patient’s personal values and preferences.

USE OF THE CARDIAC TROPONIN TEST

e high-sensitivity troponin test is a newer method

to help rule out myocardial infarction (MI). A cohort

study compared patients in emergency departments in

the United States and the United Kingdom.

e high-

sensitivity troponin test result was elevated in about one

out of eight patients (13.7%) presenting with chest pain,

although the prevalence of MI was

only 1.6% within 30 days of presenta-

tion. In emergency departments, the

positive predictive value of an ele-

vated troponin level for the diagnosis

of MI was about 60% in the United

Kingdom but only 16% in the United

States. Interestingly, a negative high-

sensitivity troponin test result eec-

tively ruled out MI (negative predictive

value 100%). Although eectively rul-

ing out MI helps in safely discharging

patients from the emergency depart-

ment, for Choosing Wisely in practice,

physicians should avoid blanketly test-

ing patients with a low pretest likeli-

hood of MI, because high-sensitivity

troponin testing in these patients will

mislead more than enlighten.

Miscellaneous

ere are four more POEMs that pro-

vide guidance for Choosing Wisely

(Table 5

17-20

POSTMENOPAUSAL ATROPHIC

VAGINITIS

Do you routinely recommend non-

prescription nonhormonal lubricants

before vaginal estrogen for patients

with symptomatic postmenopausal

atrophic vaginitis? Some women pre-

fer to avoid estrogen. A trial of 302

postmenopausal women with pain-

ful intercourse, dryness, or itching

showed that less-expensive and low-

er-risk lubricants (e.g., Replens) are

equally eective as vaginal estrogen

tablets, 10 mcg.

About one-half of

the women in each group experienced

improvement, dened by a clinically important change in

scores on a four-point scale. Of note, this study does not

evaluate whether estrogen as a cream or at a higher dose

could provide greater benet.

NPH INSULIN

In a cohort study of patients with type 2 diabetes mellitus,

NPH insulin was found to meet the STEPS (Safety, Toler-

ability, Eectiveness, Price, Simplicity) criteria, except for

simplicity because of the twice daily dosing, when com-

pared with long-acting insulin analogues (e.g., glargine

TABLE 4

Cardiovascular Disease

POEM title Clinical actions to consider for Choosing Wisely

Good reasons not to lower

the deﬁnition of high blood

pressure in adults

In adults who are not at high risk of cardiovas-

cular disease, do not adopt a lower threshold

for the deﬁnition of high blood pressure.

Cardiac troponin often falsely

elevated in patients at low risk

In patients with chest pain, avoid cardiac

troponin testing in those with a low pretest

likelihood of myocardial infarction.

POEM = patient-oriented evidence that matters.

Information from references 14 and 15.

TABLE 5

Miscellaneous

POEM title

Clinical actions to consider for

Choosing Wisely

Estrogen no better than vaginal

lubricant for postmenopausal vaginal

symptoms

In symptomatic postmenopausal

atrophic vaginitis, do not routinely

recommend vaginal estrogen in tablet

form, because a nonprescription non-

hormonal lubricant may be equivalent.

NPH insulin: fewer episodes of severe

hypoglycemia than analogs (Lantus and

Levemir) and less than half the cost

In adults with type 2 diabetes mellitus,

NPH is a cost-eective alternative to

insulin analogues.

Ibuprofen and morphine provide simi-

lar post-op pain relief in kids; ibuprofen

has fewer harms

In children with postoperative pain,

do not routinely prescribe morphine

over ibuprofen.

Bath oil does not improve eczema

symptoms in children (BATHE)

In children with atopic dermatitis, do

not recommend adding bath oil to

the bath.

POEM = patient-oriented evidence that matters.

Information from references 17-20.

294 American Family Physician www.aafp.org/afp Volume 100, Number 5

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September 1, 2019

POEMS AND CHOOSING WISELY

[Lantus], detemir [Levemir]).

For Choosing Wisely, this

study reminds us that the new is not necessarily better than

the old.

IBUPROFEN VS. MORPHINE FOR POSTOPERATIVE PAIN

IN CHILDREN

A carefully designed and adequately powered random-

ized controlled trial found no dierence in pain reduction

between ibuprofen, 10 mg per kg, and oral morphine, 0.5 mg

per kg, in children who underwent minor outpatient ortho-

pedic surgery (most commonly hardware removal, open

reduction and internal xation of a fracture, or arthroscopy).

Adverse eects, primarily nausea, vomiting, drowsiness, and

dizziness, were much more likely with morphine.

BATH OIL

In children with atopic dermatitis, a well-designed trial

using a seven-question patient-oriented eczema measure

found no benet from adding an oil-based emollient to bath

water.

Skipping the bath oil will decrease the risk of harm

from a slip in an oily bathtub.

Editor’s Note: This article was cowritten by Dr. Mark Ebell,

who is deputy editor for Evidence-Based Medicine for AFP

and cofounder and editor-in-chief of Essential Evidence Plus,

published by Wiley-Blackwell, Inc. Because of Dr. Ebell’s

dual roles and ties to Essential Evidence Plus, the article

underwent peer review and editing by four of AFP’s medi-

cal editors. Dr. Ebell was not involved in the editorial deci-

sion-making process. —Sumi M. Sexton, MD, Editor-in-Chief

See the Top POEMs from previous years at https:// www.aafp.

org/afp/toppoems.

The Authors

ROLAND GRAD, MD, MSc, is an associate professor in the

Department of Family Medicine at McGill University, Mon-

treal, Quebec, Canada.

MARK H. EBELL, MD, MS, is a professor in the Department of

Epidemiology at the University of Georgia, Athens.

Address correspondence to Roland Grad, MD, MSc, 3755

Cote Sainte Catherine Rd., Montreal, Quebec, Canada H3T

1E2 (email: roland.grad@ mcgill.ca). Reprints are not available

from the authors.

References

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(POEMs)™ suggest potential clinical topics for the Choosing Wisely™

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2. Morgan DJ, Dhruva SS, Coon ER, et al. 2018 update on medical over-

use. JAMA Intern Med. 2019; 179(2): 240-246.

3. Grad R, Ebell MH. Top 20 research studies of 2018 for primary care

physicians. Am Fam Physician. 2019; 99(9): 565-573. Accessed June 26,

2019. https:// www.aafp.org/afp/2019/0501/p565.html

4. Paavola M, Malmivaara A, Taimela S, et al.; Finnish Subacromial

Impingement Arthroscopy Controlled Trial (FIMPACT) Investigators.

Subacromial decompression versus diagnostic arthroscopy for shoul-

der impingement: randomised, placebo surgery controlled clinical trial.

BMJ. 2018; 362: k2860.

5. Beard DJ, Rees JL, Cook JA, et al.; CSAW Study Group. Arthroscopic

subacromial decompression for subacromial shoulder pain (CSAW):

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group, randomised surgical trial. Lancet. 2018; 391(10118): 329-338.

6. Urquhart DM, Wluka AE, van Tulder M, et al. Ecacy of low-dose ami-

triptyline for chronic low back pain: a randomized clinical trial. JAMA

Intern Med. 2018; 178(11): 1474-1481.

7. Vandvik PO, Lähdeoja T, Ardern C, et al. Subacromial decompression

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8. O’Byrne PM, FitzGerald JM, Bateman ED, et al. Inhaled combined

budesonide-formoterol as needed in mild asthma. N Engl J Med. 2018;

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9. Bateman ED, Reddel HK, O’Byrne PM, et al. As-needed budesonide-for-

moterol versus maintenance budesonide in mild asthma. N Engl J Med.

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report-June-2019-wms.pdf

11. Gerber JS, Ross RK, Bryan M, et al. Association of broad- vs narrow-

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September 1, 2019

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Volume 100, Number 5 www.aafp.org/afp American Family Physician 294A

POEMS AND CHOOSING WISELY

eTABLE A

Additional Top POEMs from 2018 Consistent with the Principles of the Choosing Wisely Campaign

Clinical question Bottom-line answer

Clinical actions to consider

for Choosing Wisely

Which is a better

predictor of mortality:

ambulatory or oce-

based blood pressure

measurement?

This study supports guidelines recommending that treatment deci-

sions be based on ambulatory blood pressure monitoring rather than

in-oce blood pressure results. The dierence between the two

measurements in this cohort was 19/11 mm Hg, which is enough

to change the decision to prescribe a medication at all or to add a

second or third medication.

In patients with elevated

blood pressure, do not

empirically treat without

considering the use of an

ambulatory monitor to clar-

ify prescribing decisions.

Is a single oce-

based blood

pressure measure-

ment reliable to

assess hypertension?

Do not rely on a single blood pressure measurement. The ﬁrst blood

pressure reading taken during an oce visit will be substantially

dierent than subsequent readings in almost one-half of typical

patients and, if relied on, will result in one out of eight patients being

falsely labeled as hypertensive.

In patients with elevated

blood pressure, do not rely

on a single blood pressure

measurement.

In patients with high

blood pressure, does

a second reading

show lower results?

If you are not rechecking high blood pressures, you should. Set your

electronic health record to prompt you to do it. In this large study,

when reminded, clinicians rechecked elevated blood pressures 83%

of the time, ﬁnding a median drop in blood pressure of 8 mm Hg

during the same visit. That drop is equivalent to a typical reduction in

blood pressure with pharmacologic treatment over time and resulted

in one-third fewer patients being labeled as hypertensive at that visit.

In patients with elevated

blood pressure, avoid single

measurements in the oce.

At what systolic blood

pressure threshold

should we begin

treatment for the

most beneﬁt?

Beginning antihypertensive treatment when the systolic blood

pressure is greater than 140 mm Hg delays death and prevents major

cardiovascular events in some people without preexisting heart dis-

ease; in patients with existing heart disease, it prevents further events

but does not extend life. These results may appear to conﬂict with

those from SPRINT, which found beneﬁt with lowering systolic blood

pressure to below 120 mm Hg. However, the SPRINT investigators

measured blood pressure using automated devices, which give read-

ings 10 to 20 mm Hg lower than typical oce-based measurements.

So, the goal of less than 120 mm Hg in the SPRINT study is likely to

be very similar to the goal of less than 140 mm Hg in this study.

In patients with elevated

blood pressure, do not

routinely prescribe medi-

cations unless the systolic

blood pressure is greater

than 140 mm Hg.

Is lower systolic blood

pressure associated

with better outcomes

in elderly patients

who take antihyper-

tensive medications?

In this small cohort study of patients older than 85 years, lower

systolic blood pressure during treatment with antihypertensive med-

ication is associated with higher death rates and greater cognitive

decline.

In patients older than 85

years taking antihyperten-

sive medications, do not

attempt treatment to blood

pressure targets of 120 mm

Hg systolic.

Are short courses of

antibiotics as eective

as longer courses for

common outpatient

infections?

Just about every time someone asks, “Can I get away with a shorter

course of antibiotics,” the answer is, “Yes, you can.” Shorter courses

reduce costs and may reduce the likelihood of adverse events in anti-

biotic treatment of streptococcal pharyngitis, community-acquired

pneumonia, otitis media, acute sinusitis, urinary tract infection, and

acute pyelonephritis.

In treating common out-

patient infections, do not

routinely prescribe longer

courses of antibiotics.

continues

NOTE: These POEMs are discussed in a previous issue of American Family Physician at https:// www.aafp.org/afp/2019/0501/p565.

ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; CVD = cardiovascular disease; SPRINT = Systolic Blood

Pressure Intervention Trial.

BONUS DIGITAL CONTENT

294B American Family Physician www.aafp.org/afp Volume 100, Number 5

◆

September 1, 2019

POEMS AND CHOOSING WISELY

eTABLE A (continued)

Additional Top POEMs from 2018 Consistent with the Principles of the Choosing Wisely Campaign

Clinical question Bottom-line answer

Clinical actions to consider

for Choosing Wisely

Which treatments are

safe and eective for

cough associated with

the common cold?

This expert panel report found little evidence of beneﬁt for most

commonly used medications for the self-limited condition of the

common cold. Ultimately, physicians must often act in the absence

of good evidence, and it is reasonable to recommend safe options for

the treatment of cough even if the optimal evidence is not available.

These treatments include honey in children older than one year, dex-

tromethorphan after two years of age, and possibly zinc if taken early.

In people with acute or

subacute cough, do not

expect treatment to provide

much beneﬁt.

Which treatments for

subacute cough are

eective?

The available evidence for treating patients with subacute cough is

limited and does not demonstrate meaningful improvements.

Are opioid medica-

tions preferable for

improving pain-

related function in

adults with severe

chronic back, hip, or

knee pain?

Nonopioid medications were at least as eective as opioid medica-

tions for improving pain-related function over 12 months in adults

with severe chronic back pain or hip or knee osteoarthritis pain. The

evidence that opioids are not superior to nonopioid medications for

both chronic and acute pain continues to mount. The tough job will

be getting patients and clinicians to believe the evidence.

In adults with severe

chronic back, hip, or knee

pain, do not assume that

opioid medications are bet-

ter at improving function or

reducing pain better than

nonopioids.

What oral analgesic

combinations are

eective for reducing

the pain of an acute

extremity injury in

adults in the emer-

gency department?

A10

In adults with pain severe enough to warrant radiologic investiga-

tion, ibuprofen plus acetaminophen was equally eective in reducing

pain intensity at two hours compared with three dierent opioid and

acetaminophen combination analgesics. In a similar study, naproxen

alone was as eective as naproxen plus oxycodone/acetaminophen or

naproxen plus cyclobenzaprine for reducing pain from acute muscu-

loskeletal low back pain.

A11

It is time to stop believing that opioids are

superior to nonsteroidal anti-inﬂammatory drugs for acute pain control.

In adults with an acute

extremity injury, do not

assume that opioids are

more eective at reduc-

ing pain than non-opioid

analgesics.

Are anticonvulsants

an eective treatment

for low back pain?

A12

The use of anticonvulsants, such as gabapentin (Neurontin), for

painful conditions has increased greatly in recent years. However,

this systematic review found good evidence that these drugs are not

eective for the treatment of low back pain, with or without radicu-

lopathy, and are associated with an increased risk of adverse events.

In adults with low back pain

or lumbar radicular pain,

do not routinely prescribe

anticonvulsants, such as

gabapentin.

In older people with-

out a history of CVD,

is statin treatment

associated with better

outcomes?

A13

In this retrospective study, statin treatment in patients 75 years or

older without preexisting CVD did not change the likelihood of

developing CVD or reduce all-cause mortality. However, patients

75 to 84 years of age with diabetes mellitus beneﬁted from treat-

ment. These results are consistent with ALLHAT ﬁndings.

In nondiabetic patients

75 years or older without

CVD, do not initiate a statin

without a thorough dis-

cussion of the uncertainty

around harms and beneﬁts.

continues

NOTE: These POEMs are discussed in a previous issue of American Family Physician at https:// www.aafp.org/afp/2019/0501/p565.

ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; CVD = cardiovascular disease; SPRINT = Systolic Blood

Pressure Intervention Trial.

September 1, 2019

◆

Volume 100, Number 5 www.aafp.org/afp American Family Physician 294C

POEMS AND CHOOSING WISELY

eTABLE A (continued)

Additional Top POEMs from 2018 Consistent with the Principles of the Choosing Wisely Campaign

Clinical question Bottom-line answer

Clinical actions to consider

for Choosing Wisely

Is low-dose aspi-

rin eective for the

primary prevention of

CVD in moderate-risk

patients?

A14

In this study, after ﬁve years of treatment, patients at moderate risk of

heart disease who took low-dose aspirin did not show a decrease in

coronary events and all-cause mortality and had slightly more, albeit

mostly minor, gastrointestinal bleeding. Using aspirin for primary pre-

vention of CVD is not a one-size-ﬁts-all proposition and may be less

beneﬁcial than previously thought.

In people at low or moder-

ate risk of developing heart

disease, do not initiate low-

dose aspirin.

NOTE: These POEMs are discussed in a previous issue of American Family Physician at https:// www.aafp.org/afp/2019/0501/p565.

ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; CVD = cardiovascular disease; SPRINT = Systolic Blood

Pressure Intervention Trial.

Information from:

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J Med. 2018; 378(16): 1509-1520.

A2. Burkard T, Mayr M, Winterhalder C, et al. Reliability of single oce blood pressure measurements. Heart. 2018; 104(14): 1173-1179.

A3. Einstadter D, Bolen SD, Misak JE, et al. Association of repeated measurements with blood pressure control in primary care. JAMA Intern Med.

2018; 178(6): 858-860.

A4. Brunström M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels:

a systematic review and meta-analysis. JAMA Intern Med. 2018; 178(1): 28-36.

A5. Streit S, Poortvliet RK, Gussekloo J. Lower blood pressure during antihypertensive treatment is associated with higher all-cause mortality and

accelerated cognitive decline in the oldest-old. Data from the Leiden 85-plus Study. Age Aging. 2018; 47(4): 545-550.

A6. Dawson-Hahn EE, Mickan S, Onakpoya I, et al. Short-course versus long-course oral antibiotic treatment for infections treated in outpatient

settings: a review of systematic reviews. Fam Pract. 2017; 34(5): 511-519.

A7. Malesker MA, Callahan-Lyon P, Ireland B, et al.; CHEST Expert Cough Panel. Pharmacologic and nonpharmacologic treatment for acute cough

associated with the common cold: CHEST Expert Panel Report. Chest. 2017; 152(5): 1021-1037.

A8. Speich B, Thomer A, Aghlmandi S, et al. Treatments for subacute cough in primary care: systematic review and meta-analyses of randomised

clinical trials. Br J Gen Pract. 2018; 68(675): e694-e702.

A9. Krebs EE, Gravely A, Nugent S, et al. Eect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or

hip or knee osteoarthritis pain: the SPACE Randomized Clinical Trial. JAMA. 2018; 319(9): 872-882.

A10. Chang AK, Bijur PE, Esses D, et al. Eect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency

department: a randomized clinical trial. JAMA. 2017; 318(17): 1661-1667.

A11. Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back

pain: a randomized clinical trial. JAMA. 2015; 314(15): 1572–1580.

A12. Enke O, New HA, New CH, et al. Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-

analysis. CMAJ. 2018; 190(26): e786-e793.

A13. Ramos R, Comas-Cufí M, Martí-Lluch R, et al. Statins for primary prevention of cardiovascular events and mortality in old and very old adults

with and without type 2 diabetes: retrospective cohort study. BMJ. 2018; 362: k3359.

A14. Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovas-

cular disease (ARRIVE). Lancet. 2018; 392(10152): 1036-1046.