BMJ Global Health: Evidence-based medicine for all – UpToDate

CITATION: Evidence-based medicine for all: what we can learn from a programme providing free access to an online clinical resource to health workers in resource-limited settings

Yannis K Valtis, Julie Rosenberg, Sudip Bhandari, Keri Wachter, Marie Teichman, Sophie Beauvais, Rebecca Weintraub

Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041

Correspondence to Dr Rebecca Weintraub:


The rapidly changing landscape of medical knowledge and guidelines requires health professionals to have immediate access to current, reliable clinical resources. Access to evidence is instrumental in reducing diagnostic errors and generating better health outcomes. UpToDate, a leading evidence-based clinical resource is used extensively in the USA and other regions of the world and has been linked to lower mortality and length of stay in US hospitals. In 2009, the Global Health Delivery Project collaborated with UpToDate to provide free subscriptions to qualifying health workers in resource-limited settings. We evaluated the provision of UpToDate access to health workers by analysing their usage patterns. Since 2009, ~2000 individual physicians and healthcare institutions from 116 countries have received free access to UpToDate through our programme. During 2013–2014, users logged into UpToDate ~150 000 times; 61% of users logged in at least weekly; users in Africa were responsible for 54% of the total usage. Search patterns reflected local epidemiology with ‘clinical manifestations of malaria’ as the top search in Africa, and ‘management of hepatitis B’ as the top search in Asia. Our programme demonstrates that there are barriers to evidence-based clinical knowledge in resource-limited settings we can help remove. Some assumed barriers to its expansion (poor internet connectivity, lack of training and infrastructure) might pose less of a burden than subscription fees.

SELECTED EXTRACTS (selected by Neil PW)

‘according to WHO estimates, there are more than 100 000 physicians working in low-income countries; yet, only 1948 health workers applied for access to our programme.’

‘The relevance, or lack thereof, of EBCRs [Evidence based clinical reseources] in general, and UpToDate in particular, to LMIC clinical needs has not been evaluated: It is possible that UpToDate’s recommendations on clinical care are different from, and even in conflict with, local practice and guidelines. It is also possible that UpToDate recommends the use of diagnostic procedures and

therapeutic interventions that are unavailable in LMICs due to high cost or other constraints.’

‘It is clear that cost is one barrier to EBCRs that will need to be removed to realise the vision for evidence-based medicine for all. We are hopeful that the next steps towards this vision will be

bigger and broader and close the knowledge gap quickly.’

In an interview on Global Health Hub, the lead author puts forward an interesting hypothesis on the finding that topics such as heart failure, stroke, diabetes, and hypertension were extremely popular. One reason for this is of course the rising burden of NCDs. But another possible explanation is that existing guidance (and experience) on NCDs might not be widespread as compared with guidance on diseases that haave always been common, such as malaria.

Best wishes, Neil

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