Top POEMs of 2022 for choosing wisely in practice

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

Table 1.

POEMs of 2022 aligned with CWC recommendations

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.

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.

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.

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

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@choosingwiselycanada.org.