Each year, thousands of studies are published that are potentially relevant to primary care physicians. To help physicians identify the most important new research, the POEMs (patient-oriented evidence that matters) criteria were developed. According to these criteria, the most important research—defined as research that, if true, has the greatest potential to change practice—should be relevant and valid (i.e., at low risk of bias), and report patient-oriented outcomes such as morbidity, mortality, or quality of life.¹ Since 1994, a team of primary care clinicians with expertise in evidence-based practice has performed monthly surveillance of more than 110 English-language research journals.² Although more than 20,000 studies were published in these journals during 2016, only 264 met the POEMs criteria for validity, relevance, use of patient-oriented outcomes, and practice change. Each POEM is summarized in a structured critical appraisal written by one of the six expert reviewers and peer reviewed by faculty and fellows of the University of Missouri Department of Family Medicine. Writing and disseminating the POEMs are supported by subscriptions, without industry support.

The Canadian Medical Association (CMA) sponsors a subscription to the Daily InfoPOEMs for their members. Each member has the option to receive the daily POEM by e-mail and rate it using a brief survey called the Information Assessment Method. This validated survey is a tool to document clinical relevance, cognitive impact, use of the information in practice, and expected health benefits for patients if the results of the POEM are applied.³ This article presents the 20 POEMs of 2016 that were most highly rated by CMA members for clinical relevance to one or more of their patients.

In the sixth installment of this annual series,^4–8 we summarize the clinical question and bottom-line answer for each of the 20 top-rated POEMs. The POEMs have been organized by topic, and each is accompanied by a brief discussion. The bottom-line answers have been rewritten somewhat from the original to better stand alone without the complete synopsis. We also briefly discuss four POEMs that summarize highly relevant practice guidelines.

Hypertension

The first group of POEMs focuses on hypertension (Table 1).^9–14 Study 1, the SPRINT (Systolic Blood Pressure Intervention Trial) study, reported a reduction in all-cause and cardiovascular (CV) mortality in older high-risk patients without diabetes mellitus who were randomized to a more intensive systolic blood pressure target of 120 mm Hg.⁹ The number needed to treat (NNT) for 3.3 years was 83 to prevent one death, but this is balanced by more harms: hypotension (number needed to harm [NNH] = 100), syncope (NNH = 200), electrolyte abnormality (NNH = 125), and acute kidney injury (NNH = 59). There was no effect on rates of myocardial infarction or stroke.

Study 2 found no benefit to blood pressure lowering in patients at intermediate CV risk who already had a systolic blood pressure less than 143 mm Hg.¹⁰ This trial included some patients with diabetes or impaired glucose tolerance, but overall, the patients were at lower risk than persons in the SPRINT trial (CV event rate = 0.8% vs. 2.1%). Thus, the decision to pursue a more aggressive blood pressure target should involve the patient and should be limited to patients without diabetes who are at high risk of a CV event. Study 3, a systematic review, also addresses more aggressive blood pressure control.¹¹ Although the authors found very small reductions in CV events, many of the studies were of poor quality or did not achieve a large difference in systolic blood pressure between groups. This is an area that needs further study, and, for now, we should remain cautious about extending tight control to all patients with hypertension.

Study 4 highlights the need to consider a patient's baseline CV risk when making decisions about statin therapy.¹² Statin use at the dosage given in this study reduces the likelihood of a CV event by approximately 25%. So, if the starting point is a 10-year CV event risk of 20%, statin use would reduce the risk to 15%, for an NNT of 20. If the 10-year risk is 10%, as in this study, it reduces the likelihood to 7.5%, for an NNT of 40. If the 10-year risk is only 5%, it reduces the likelihood to 3.75%, for an NNT of 80. These numbers should inform discussions with patients about their preferences for statin therapy. Study 5 compared three drugs in patients with poorly controlled hypertension who were already receiving maximal dosages of three antihypertensives.¹³ Spironolactone was the most effective at lowering blood pressure. Although blood pressure reduction is not a patient-oriented outcome, the study was not powered or of adequate duration to evaluate CV events or mortality. Finally, Study 6 makes us reconsider the name of the condition now known as hypertensive urgency, because CV events were rare during the week after patients presented with a blood pressure greater than 180/110 mm Hg.¹⁴ Although it is important to work with these patients to improve blood pressure control and address medication adherence (a common cause of this problem), it is rarely life threatening.

Respiratory Conditions

Three of the selected POEMs address respiratory conditions (Table 2).^15–17 In Study 7, patients 12 years and older with moderate to severe asthma were randomized to receive twice-daily inhaled fluticasone (Flovent) alone, with a dose stratified by disease severity, or combination fluticasone/salmeterol (Advair; stratified dose/50 mcg).¹⁵ For every 50 patients who received fluticasone/salmeterol, there was one fewer severe exacerbation over a six-month study period. However, there was no difference in hospitalizations.

The next two POEMs focused on the treatment of respiratory tract infections. In Study 8, primary care patients with chronic or recurrent nasal symptoms were randomized to receive a recommendation to perform daily nasal saline irrigation or a recommendation to perform daily steam inhalation. Only the nasal saline irrigation was effective.¹⁶ This is consistent with studies of patients with chronic rhinosinusitis in the United States. Finally, Study 9 is a Spanish primary care study in which the physicians had reasonable doubt as to whether to treat a patient with an antibiotic. Patients were randomized to an immediate antibiotic, no antibiotic, or one of two delayed antibiotic strategies.¹⁷ Although the patients who did not get an antibiotic had a longer duration of symptoms, there was little difference between the delayed prescribing strategies and the immediate antibiotic group. The delayed strategies were associated with fewer days off work and similar patient satisfaction.

Musculoskeletal Conditions

Several POEMs address care of patients with hip, knee, or back pain (Table 3).^18–20 Study 10 was a meta-analysis of 74 trials with 59,000 patients comparing seven different drugs for osteoarthritis of the hips or knees.¹⁸ Although all medications were effective, including acetaminophen, the most likely to provide meaningful pain relief were diclofenac and rofecoxib (which is no longer available). However, these drugs have greater potential for harm than acetaminophen. Study 11 examined the value of opioid analgesics in patients with low back pain.¹⁹ This was a meta-analysis of 20 studies with 7,295 patients, mostly with chronic low back pain. The researchers found that the benefits of opioids were modest and that many patients discontinue treatment because of adverse effects or lack of effectiveness. Patients who dropped out were considered nonresponders, which may not be accurate as they may have dropped out because of adverse effects, despite effective pain reduction. The final musculoskeletal pain POEM, Study 12, used data from two observational studies to determine the value of radiography for the diagnosis of hip pain.²⁰ Only 21% of patients who met the criteria for hip osteoarthritis on radiography had frequent hip pain, whereas only 16% of patients with frequent hip pain had radiographic evidence of hip osteoarthritis. Using radiography alone to guide treatment decisions about suspected hip osteoarthritis is therefore unreliable.

Diabetes Mellitus and Obesity

In Study 13, the first of three selected POEMs related to the treatment of diabetes and obesity (Table 4^21–23 ), a meta-analysis of 49 studies with 73,738 participants found that there was no benefit to giving antihypertensives to patients with a baseline blood pressure less than 140 mm Hg.²¹ There was some benefit to treating blood pressures greater than 140 mm Hg, with decreases in all-cause mortality, end stage renal disease, and CV mortality and events.

An important challenge of caring for patients with type 2 diabetes is balancing the benefits and harms of treatment. Study 14 used data from a registry of 26,000 patients in the United Kingdom who had diabetes and were older than 80 years.²² They found that the association between mortality and glycemic control was U-shaped, with the best outcomes for patients with an A1C level between 7.0% and 7.5%, and a blood pressure between 150/90 and 155/95 mm Hg. This is consistent with randomized trials showing no benefit or harm with aggressive targets for blood pressure control. Finally, Study 15, a meta-analysis of five studies with 998 patients, most of whom had type 2 diabetes, found that a Mediterranean diet was associated with an average weight loss of 3.8 to 10.1 kg (8.4 to 22.3 lb).²³ This compares with a loss of 5.0 kg (11.0 lb) to a gain of 2.9 kg (6.4 lb) in studies of a low-fat diet. Other studies have shown that a Mediterranean diet, which includes olive oil, fish, vegetables, and nuts, is associated with fewer CV events.

Miscellaneous

The remaining five POEMs do not fit neatly into a single category but provide useful guidance for family physicians (Table 5).^24–28 Study 16 randomized patients who wanted to quit smoking to a gradual reduction in tobacco use or an abrupt quit date. Going cold turkey, preceded by two weeks of nicotine replacement patch use, was more effective, even in patients who expressed a preference for a go-slow approach.²⁴

Primary care physicians commonly evaluate patients with eye symptoms. In Study 17, a systematic review of diagnostic studies concluded that photophobia via pupillary constriction and the presence of anisocoria are the best predictors of serious eye disease, such as uveitis, keratitis, or scleritis, whereas the absence of sticky matting in the morning helps rule out bacterial conjunctivitis.²⁵

Options for the treatment of genital chlamydial infection include a single dose of azithromycin, 1 g, or doxycycline, 100 mg twice daily for seven days. Study 18, a randomized trial, found a slightly higher failure rate with azithromycin: five out of 155 (3.2%) patients vs. none in the doxycycline group.²⁶ However, because the study took place in a youth correctional facility, 45% of study participants were released before the final evaluation of cure. Additionally, adherence to the study medication could be assured because of the nature of the setting; therefore, despite the slightly higher failure rate, if adherence is a concern, azithromycin may be the better option.

Study 19 used data from a large French patient registry with more than 5 million woman-years of contraceptive use to determine the risk of CV events.²⁷ Overall, the risk was very low (six events per 10,000 woman-years), and it was lowest in women taking a lower-dose estrogen (20 mcg) and with levonorgestrel as the progestogen component.

Finally, Study 20 asked parents to read a prescription label and then use an oral syringe or a medicine cup to dose the liquid medication.²⁸ Approximately 84% of parents made at least one error in their three dosing attempts. Using a syringe was far more accurate and should be recommended to parents of young patients.

Practice Guidelines

In addition to the top 20 original research studies, members of the CMA identified four guideline reports among the highest-rated POEMs. Two guidelines from the U.S. Preventive Services Task Force were highly rated. The first is an updated recommendation on colorectal cancer screening. A key message is that all approaches are effective, adding 225 to 245 life-years per 1,000 patients screened. The primary difference between strategies, as shown in a series of useful figures in the guideline, was the number of lifetime colonoscopies required, which was greatest with colonoscopy and the fecal immunochemical DNA test.²⁹ The cost is highest for those strategies as well. Fecal immunochemical testing is the preferred stool test and is being compared with colonoscopy in several ongoing randomized trials. [Two editorials discussing colorectal cancer screening methods are available at https://www.aafp.org/afp/2017/0515/p616.html and https://www.aafp.org/afp/2017/0515/p618.html.] The second guideline serves as a reminder to ask all adults about tobacco use, advise them to stop, and offer help in terms of nicotine replacement or other pharmacotherapy to enhance their likelihood of success.³⁰ The evidence was insufficient to make any recommendations on the use of e-cigarettes to reduce the use of traditional cigarettes.

The American College of Physicians released an evidence-based guideline on the treatment of chronic insomnia.³¹ The preferred initial treatment is cognitive behavior therapy focused on stimulus control, sleep restriction, sleep hygiene, and relaxation techniques. Drug therapy is somewhat effective, but there are no long-term studies, and these medications all have the potential for adverse effects. Some drugs in fairly widespread use, like diphenhydramine and trazodone, have not been studied for the treatment of chronic insomnia.

Finally, the Centers for Disease Control and Prevention (CDC) released a guideline for prescribing opioids in patients with chronic pain.³² Based largely on low-quality evidence and short-term studies, the CDC recommends using nonpharmacologic therapies first, establishing realistic goals, discussing risks and benefits with patients before initiation, using the lowest effective dose, and providing close follow-up. Referral to a pain management subspecialist is recommended when the dose exceeds 50 to 90 morphine milligram equivalents per day.

editor's note: This article was cowritten by Dr. Mark Ebell, who was a member of the U.S. Preventive Services Task Force (USPSTF) from 2012 to 2015 and currently serves as a consultant to the USPSTF. This article does not necessarily represent the views and policies of the USPSTF. Dr. Ebell is deputy editor for American Family Physician (AFP) and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc. The POEMs described in this article stem from work that Dr. Ebell and his colleagues have been doing for the past two decades. Medical journals occasionally publish an article summarizing the best studies in a certain field from the previous year; however, those articles are limited by being one person's idiosyncratic collection of a handful of studies. In contrast, this article by Drs. Ebell and Roland Grad is validated in two ways: (1) the source material (POEMs) was derived from a systematic review of thousands of articles using a rigorous criterion-based process, and (2) these “best of the best” summaries were rated by thousands of Canadian primary care physicians for relevance and benefits to practice.

Because of Dr. Ebell's dual roles and ties to Essential Evidence Plus, the concept for this article was independently reviewed and approved by a group of AFP's medical editors. In addition, the article underwent peer review and editing by three of AFP's medical editors. Dr. Ebell was not involved in the editorial decision-making process.—Jay Siwek, MD, Editor, American Family Physician

The authors thank Wiley-Blackwell, Inc., for giving permission to excerpt the POEMs; Drs. Allen Shaughnessy, Henry Barry, David Slawson, Nita Kulkarni, and Linda Speer for their work in selecting and writing the original POEMs; the academic family medicine fellows and faculty of the University of Missouri–Columbia, for their work as peer reviewers; Pierre Pluye, PhD, for his work in codeveloping the Information Assessment Method; and Maria Vlasak for her assistance with copyediting the POEMs for the past 23 years.