What to Do Until the POEMs Arrive

The bottom line

What do we do until the POEMs arrive? Clearly, we can wait for POEMs, but such delays would paralyze clinicians and deny patients many excellent treatments. POEMs, especially POEMs of effectiveness, should help mold practices. Practicing without POEMs has risks, so it is necessary to carefully evaluate the existing evidence in light of the potential benefits, the potential harms, and the likelihood of these outcomes.

For the example of ACE inhibitors, the case seems fairly clear-cut. The causal pathway fits a growing basic science. Extensive DOEs and POEMs have provided support for the links of the causal pathway, reassuring physicians that the pathway is relevant to practice. In addition, ACE inhibitors show a growing usefulness for noncardiovascular diseases, such as diabetic nephropathy, and for nonvascular cardiac disease, such as congestive heart failure. As a class, ACE inhibitors are generally well tolerated in most patients.^17,38-40 Until the final POEMs arrive, the use of ACE inhibitors in a variety of cardiovascular diseases seems justified.

When faced with a sufficient weight of POEMs, patients can be shown good evidence to support suggested treatment strategies. Without this evidence, it is necessary to weigh the pros and cons, including the likelihood of benefit and harm, and make a decision. An understanding of pathophysiologic mechanisms helps physicians construct good causal pathways. Finding evidence, usually in the form of DOEs, to support the links of the pathway is often the best way to proceed while waiting for the POEMs to arrive.

Acknowledgments

This work was supported, in part, by a grant from Medical Education Systems, Inc.