UpToDate Systematic Narrative Review – Thematic Tables Giustini, Wang, Read – October 2011 UpdateStatement of Problem: In the provision of point-of-care (POC) tools, few products seem to causethe level of debate and disagreement than the Wolters Kluwer product, UpToDate (UTD). On theone hand, there are health librarians who view the tool as overpriced – and simply not as currentor evidence-based as its popularity might suggest. On the other, there are the medical students,residents and physicians (especially those in internal medicine, primary care; and subspecialities,cardiovascular medicine and endocrinology to oncology, rheumatology and surgery) whofrequently ask for it and rate it among the best POC tools available. As a group of health librariansand clinicians, we wondered whether the apparent differences of opinion and viewpoint aboutUTD’s value in the clinical setting would be borne out in the literature. We sought to examine theevidence by performing a systematic search and narrative review/analysis of all papers about UTDin head-to-head comparisons, evaluations and other empirical studies.Research Questions:1. What is the consensus in the literature about UpToDate and its value to clinical decision-making?2. What are the differences between how UpToDate is perceived by medical and libraryprofessionals? For example, currency; ease of use; evidence-based methods; number ofreferences. What are the most obvious differences?3. What can medical and library professionals learn from each other about UpToDate?4. In the absence of UpToDate in hospitals and health organizations, what other POC sourcesmight be viewed as suitable more cost-effective replacements (or complements)?Theme 1: Head to head comparisons of point-of-care tools – 10 papers (1 paper addedOct 1st )Theme 2: Physicians’ use of UpToDate vs. other resources – 18 papers (2 papers addedOct 1st )Theme 3: Quality of Hospital and / or Library with access to UpToDate – 2 papersTheme 4: Survey of Physician/Librarian Usage of UpToDate – 20 papersAppendix: Additional papers that mention UpToDate n=50 papers (as of October 1st 2011)
Theme 1: Head-to-head comparisons of point-of-care tools Banzi (2), Burkiewicz (Ketchum, Ketterman, Shurtz, Taylor, Trumble – Librarians, Sayyah, Turan = 10 papersStudy authors / journal Date Tools used in Results Methods ComparisonBanzi R, Cinquini M, Liberati a, et 2011 Clinical Evaluated updating EBM Guidelines,al. Speed of updating online Evidence, speed by measuring UpToDate, andevidence based point of care Dynamed, incidence of research Dynamed refer to “asummaries: prospective cohort EBM findings in POC continuous update,”analysis. BMJ. 2011;343(sep22 Guidelines, summaries on meaning that new2):d5856-d5856 eMedicine, potentially eligible research findings are and UpToDate newsworthy pieces incorporated into the of information summaries every time they are Selected all published. systematic reviews by American College UpToDate is the only of Physicians (ACP) product that clearly Journal Club and reports quantitative Evidence-Based data on the topic Medicine Primary updated (35% of all Care and Internal contents during a Medicine four month cycle). How fast point of Cochrane systematic care summaries are reviews were more updated - used a likely to be cited by prospective cohort1 EBM Guidelines than design over one year by UpToDate Dynamed clearly dominates the other products in terms of updatingBanzi R, Liberati A, Moschetti I, 2010 Identifies 18 Selected EBP point of UpToDate ranked #2 onTagliabue L, Moja L. A review of EBP POC care tools through editorial quality; #4 ononline evidence-based practice summary Medline searches, evidence basedpoint-of-care information providers, inc. Google, library methodology scoressummary providers. J Med UpToDate websites, conferenceInternet Res. 2010;12(3):1-16. proceedings in 2008 Not about UpToDatehttp://www.jmir.org/2010/3/e26/ Assessed coverage, specifically but ranked in editorial quality / top quartile for ebm EBM methods in scores / editorial quality tools1 Two reviewers independently checked whether each sampled systematic review was cited in at least one chapter ofthe five point of care information summaries. This was done monthly at the same time for each product.
Burkiewicz JS, Vesta KS, Hume 2005 FIRSTConsult, Review of handheld Describes features/AL. Update in handheld InfoRetriever, e-resources for EBP requirements of each;electronic resources for and UpToDate utility in community UpToDate requires largeevidence-based practice in the pharmacy setting system memorycommunity setting. AnnPharmacother. Searched (Nothing else provided inDec;39(12):2100-4. Medline/Internet this summary?)http://www.ncbi.nlm.nih.gov/pubmed/16288067?dopt=AbstractKetchum AM, Saleh AA, Jeong K. 2011 ACP PIER, 6 tools & four topics: Clinical Evidence & Type of evidence behind point- Clinical asthma/hypertension DynaMed show higher %of-care clinical information Evidence, hyperlipidemia/ of citations for asthmaproducts: a bibliometric analysis. DynaMed, carbon monoxide while ACPPIER andJ Med Internet Res. Feb FirstCONSULT, poisoning; UpToDate have greater %18;13(1):e21. and UpToDate comparative analysis of citations forhttp://www.jmir.org/2011/1/e21/ hypertension. Conclusion: 4 indicators: no standards for guidance distribution of on developing content for citations, type of these products; evidence, product differences in POC tools is currency & citation seen in references overlap.Ketterman, E. & Besaw, M. E. An 2010 DynaMed and Head to head UpToDate had greaterEvaluation of Citation Counts, UpToDate comparison based on number of instancesSearch Results, and Frequency of 4 criteria: search (63.8%) where initialUpdates in DynaMed® and result counts, search result count was higherUpToDate®. Journal of Electronic result answers, than DynaMed (36.2%).Resources in Medical Libraries, reference counts,7(4), 273-280. and currency of Percentage of hits slightlyhttp://www.informaworld.com/ updates higher for UpToDatesmpp/content~db=all~content=a (89.4%) compared with930553472 Total of 141 of most DynaMed (87.2%) recent topics generated UpToDate had more instances (74) where it had more references compared to DynaMed (55) DynaMed returned with more current topic 123 times, where UpToDate was more current 13xSayyah Ensan L, Faghankhani M, 2011 PubMed Participants in the First time users usingJavanbakht A, Ahmadi S-F, Clinical study were randomly UpToDate answer higherBaradaran HR. To Compare Queries and assigned to answer 2 proportion of questionsPubMed Clinical Queries and UpTodate clinical scenarios in shorter time than PubUpToDate in Teaching using either Med Clinical Queries; UTDInformation Mastery to Clinical UpToDate or is efficient because:Residents: A Crossover PubMed Clinical information is organizedRandomized Controlled Trial. PloS Queries. They then in entries rather than
One. 2011;6(8):e23487 crossed to use the articles; each discusses a other database to complaint, disease, or a answer 2 different category of a disease; clinical scenarios. A provided by integrating proportion of best evidence by experts relevantly answered to address management clinical scenarios, options for health time to answer problems and retrieval, and users recommendations are satisfaction were graded on basis of level measured in each of evidence. databaseShurtz S, Foster MJ. Developing 2011 ACP PIER, Previous studies Medical librarians play anand using a rubric for evaluating DynaMed, were designed to important role inevidence-based medicine point- Cochrane evaluate EBM tools evaluating quality of POCof-care tools. J Med Libr Assoc. Library, to answer clinical tools; assessment tools,2011 Essential questions. The goal such as rubrics, aid inJul;99(3):247-54 Evidence Plus, here was to develop evaluation; some articles and MD rubrics for assessing in lit review favoured one Consults First tools based on EBM tool BUT major Consult criteria (reviewing finding of this review is content, search current POC tools were options, quality quite similar relative to control, and grading; their content coverage searching for and search options treatments of common diagnoses and evaluating summariesTaylor B. What -- no UptoDate? 2009 (UpToDate, Compared results for FIRSTConsult yieldsRegina QuAppelle Health Region Clinical four conditions: higher levels of evidenceLibrary replaces UptoDate with Evidence hypertension, in its monographsBMJs PointofCare. JCHLA. 2009 (BMJ), ACP hyperlipidemia, followed by ClinicalDec; 30 (4): 147-8 PIER, carbon monoxide Evidence, ACP PIER, DynaMed, and poisoning, and DynaMed and UpToDate FIRSTConsult) asthma, then determined the level Studies show UpToDate of evidence of each has some competitors reference that challenge its spot as point-of-care(POC) tool favoured by physicians, medical students Trumble J, Anderson M, Caldwell 2006 3 products Study by 7 health and ACP Pier and ClinicalM, et al. A systematic evaluation self-identified medical librarians. Evidence rated as top twoof evidence based medicine tools as POC tools Texas Health Science POC tools, UpToDate fellfor point-of-care. Texas Health ranked in 18 Libraries Consortium in middle somewhereScience Libraries Consortium. In: categories,Proceedings of the 34th levels ofSCC/MLA Annual Meeting; Oct evidence, ease
20–24. College Station, (TX). of navigation,http://www.thslc.org/papers.ht and link toml PubMedTuran M, Serdar MA, Cihan M. 2008 ePocrates, Assessment based onRapid access to information Inforetrieve, # of tests included, “…it is necessary to keepresources in clinical Pepid, software several software productsbiochemistry: medical eMedicine, content of detailed in our PDAs to meet ourapplications of Personal Digital FIRST Consult, information for each demands. For example,Assistants (PDA). Clinical 5 laboratory test-like process, combining UpToDate withand Experimental Medicine.Jun ebooks interpretation of ePocrates or combining30;8(2):117-122. released by results, reference Pepid with a Skyscape Skyscape and/ ranges, critical ebook would be or Isilo) values, interferences, appropriate…” equations, pathophysiology, Regarding evaluation supplementary results, unique software technical details such is not available to as sample collection combine evidence-based principles and clinical & laboratory data additional info such as linked references, evidence-based data, test cost, etc
Theme 2: Physicians’ use of UpToDate vs. other resources to answer questions Ahmadi, Blackman, Campbell (librarian), Cao, Collier, Fenton (librarian), Frijns, Goodyear-Smith, Graber, Hoogendam, Jaeschke, Kelson, Kim, Koonce, Lucas, Patel, Schilling, Shariff, Thiele n= 18 papersStudy authors / journal Date Resources used Results Methods in comparisonAhmadi SF et al. A 2011 ACP PIER, Essential 112 residents were Attending andcomparison of answer Evidence Plus randomly allocated to resident physiciansretrieval through four (formerly four groups to use: (1) have in-hospitalevidence-based InfoRetriever),First ACP PIER, (2) Essential access to computerstextbooks (ACP PIER, Consult, and Evidence Plus (formerly capable of searchingEssential Evidence Plus, UpToDate. InfoRetriever), (3) First Best Evidence,First Consult, and Consult, and (4) Medline, UpToDate,UpToDate): a UpToDate. Participants and other evidence- received 3 of 24 based resourcesrandomized controlled questions randomly totrial. Med Teach. retrieve the answers2011;33(9):724-30. from the assigned textbook.Blackman D, Cifu A, Textbooks, 2 study sites, 4 primary UpToDate MDsLevinson W. Can an 2002 Medline, PDR, care doctors answered moreelectronic database help colleagues, web randomized to questions 34.3 vs.busy physicians answer sites UpToDate; 6 physicians 18.7 p=0.17, changeclinical questions? J Gen to controls; interviewer in pt plan 35% vs.Intern Med.; onsite 4-5 weeks spoke 19.5% p=0.2317Suppl1:220.4. to MDs after visits / resources used to Intervention-almost answer Qs / did entirely UpToDate answers changes 50%- medical patient care? Answers textbooks 13.8% recorded literature search 12.5 colleagues 6.7 678 patient visits; most Qs re: therapy, Conclusions- diagnosis access/training to UpToDate increases use; trend toward answering more Qs & change in Rx plansCampbell R, Ash J. An 2006 ACPPier, Randomized trial- Answered more Qsevaluation of five bedside DISEASEDEX, physicians, residents, with UpToDate: 2.5information products FIRSTConsult, medical students, questions usingusing a user-centered, InfoRetriever physician assistants, UpToDate, p<0.001,task-oriented approach. J physician assistant 1.9 questions inMed Libr Assoc. ;94(4): students, nurses, DISEASEDEX, 1.7435–41, e206–7. nursing students, questions in both pharmacists, and FIRSTConsult and informatics students InfoRetriever & 1.6 with current or Qs in ACP PIER.
previous clinical experience. No Better user additional training was experience p <0.001 provided Higher satisfaction with UTD p<0.006 13 (73%) ranked UpToDate the best; no one ranked it the worstCao Y, Liu F, Simpson P, 2011 AskHERMES AskHERMES allows AskHERMES’Antieau L, Bennett A, physicians to enter a performance isCimino JJ, Ely J, Yu H. question with minimal comparable to otherAskHERMES: An formulation to navigate systems; whenonline question answering among answer answering complexsystem for complex sentences to quickly clinical Qs, hasclinical questions. J meet their information potential toBiomed Inform. needs outperformApr;44(2):277-88. Google and UpToDateCollier AP, Heilig LF, 2007 Journal Medical students in Most frequently usedSchilling LM, Dellavalle article/abstracts, dermatology clinics at source of clinicalRP. Clinical questions websites and Denver VA had to information: journalasked by medical textbooks formulate and answer abstracts/ articlesstudents: a learning tool a clinical question (55%, 24/44),for dermatology during patient UpToDate (50%,rotations. encounters, then 22/44), websitesDermatology;214:108-111 complete a survey (27%, 12/44) printed about experience. textbooks (25%, 11/44). 49% (44/89) of medical students finished study Increased knowledge, confidence and patient care skills after completing exercisesFenton SH, Badgett RG. A 2007 Head to head 752 ?Qs selected from UpToDate returned 1comparison of primary comparison of clinical Qs collection of or more documentscare information content UpToDate and NLM for 580 questions,in UpToDate and the NGC NGC returned at leastNational Guideline UTD and National 1 document for 493Clearinghouse. J Med Libr Guidelines questions (77.1%AssocJul;95(3):255-9. Clearinghouse (NGC) versus 65.5% ofErratum in: J Med Libr searched utilizing question sampled, P =Assoc. 2007 keywords from ?s 0.001)Oct;95(4):473. Together they returned content for 91% of searches (n = 685).
NGC retrieved a mean of 16.3 documents per Q vs 8.7 documents from UpToDateFrijns J, Dyserinck H, Gu P, 2004 TRIP, Chose ten therapeutic Topic review is theLoep M. Finding the Cochrane Library, questions from PDQ exclusive type ofevidence for therapeutic SUMSearch. Evidence-Based study in UpToDatePICO questions on four Principles and Practiceelectronic resources. and some EBM related Users need to use oneLibrary Review. Jan Web sites and or two common1;53(3):142-149. formulated them into medical terms to the structured clinical obtain hits. Search questions by using a terms include name PICO process of disease, symptoms, trial or drug name but All search examples direct Boolean about therapeutic search, author’s interventions. For each, name, journal or year a different search not yet permitted strategy was built to be performed on four # of search results in electronic resources, UpToDate or TRIP is using MeSH, text words smaller than in or both if applicable. Cochrane or All MeSH were SUMSearch exploded Shortest time on UpToDate to get answers compared to other toolsGoodyear-Smith F, Kerse 2008 DynaMed, 200 general Favourite e-text inN, Warren J, Arroll B. MD Consult practitioners accessed questionnaire, 35Evaluation of e-textbooks. (including 3 e-textbooks. (43%, 95% CI: 32, 54)DynaMed, MD Consult FirstConsult) Completed survey and is UpToDateand UpToDate. Aust Fam used random selectionPhysician. to answer 4 clinical Users more likely toOct;37(10):878-82. questions: screening, prefer UpToDate; as a diagnosis, treatment & whole - no winner; prognosis. most-preferred text in same order as 122 GPs had at least before w 31 (43%) one hit through study rating UpToDate as site. 84 GPs completed most preferred questionnaire; 77 completed interview UpToDate often gave (36% of enrolled, 61% too much info; more of users). GPs prefer UTD as textbook of choice (43%); 75% of med
students used UTD when offered accessGraber MA, Randles BD, 2008 Print, e/textbooks, Observational study of Most common sourceEly JW, Monnahan J. Google 26 physicians at 2 paper or computerAnswering clinical institutions; physicians drug reference (47questions in the ED. Am J followed for 2 shifts; [37%] of 126Emergency Medicine. number / type of questions). OnlineFeb;26(2):144-7. questions recorded. % resources comprise answered, resources 2nd most common used, barriers to resource, (36 of 126 answering recorded or 29%) with Google and UpToDate N= 235 questions were dominating recorded or about 5 questions per 8-hour shiftHoogendam A, Stalenhoef 2008 PubMed & UpToDate answeredAF, Robbé PF, Overbeke UpToDate 40 residents & 30 more questions thanAJ. Answers to questions internists working in PubMed on all majorposed during daily patient academic medical topics but differencecare are more likely to be centers use PubMed detected whenanswered by UpToDate and UpToDate question was relatedthan PubMed. J Med according to to etiology (P < .001)Internet Res. Oct observation portal in or therapy (P = .002).3;10(4):e29. daily medical care Time to answer was Analyzed 1305 patient- 241 seconds (SD 24) related questions sent for UpToDate and 291 to PubMed and/or seconds (SD 7) for UpToDate between PubMed. October 1, 2005 and March 31, 2007 using Participants preferred portal. Complete UpToDate & answer was found in answered more 594/1125 (53%) patient-related questions sent to questions in daily PubMed or UpToDate medical care with UpToDate than PubMed Comparable to previous research: UpToDate preferred over PubMed; perceived as equal or better for patient Qs. Findings show starting search in UpToDate followed by PubMed (when
answer is not satisfactory) is sensible strategyJaeschke R. Up To Date 2000 Cochrane reviews Short review where[review] Evid Based Med colleague unfamiliar On scale from 1 (easy5: 40. with UpToDate to use), to 3 (soso), to identified 10 clinical 5 (difficult to use), questions for which UpToDate assigned good quality evidence “1” by all ten trainees is available (best mean score 1.8, Cochrane 3.8). 10 clinical trainees on clinical teaching unit in UpToDate most com- Hamilton, Ontario, monly used were asked to grade information source user friendliness of among trainees variety of evidence resources UpToDate used for general orientation to a topic - but people trying to learn more about basic biology, physiology or anatomy will want to look elsewhere. (2000 – older study)Kelson J. UpToDate rated 2007 ACP’s PIER, Participants randomlyhighest in a combined DISEASEDEX, allocated to 3 test Participants answeredtask assessment/user- FIRSTConsult, questions which they more questions withsatisfaction study of 5 InfoRetriever tried to answer using UpToDate (averageclinical information each of 5 commercially 2.5 questions)resources. Evidence Based available clinical compared to otherLibrary and Information information resources resources; rangedPractice.;2(3): 91-3. from average of 1.6 Participants were (ACP’s PIER) to 1.9 physicians (44%), (DISEASEDEX) Qs medical informatics answered students with clinical experience (28%), UpToDate scored pharmacists (17%), higher (Friedman nurse (6%) and MRI test) on ease of use, technologists (6%). clarity of screen layout and how well participants’ needs were satisfied 13 participants (73%) rated UpToDate as
best ** Caution advised with respect to conclusions as 72% of participants were familiar with UTD already **Kim S, Willett L, Murphy 2008 Ovid, InfoPOEMs All second and third- Most commonlyD, ORourke K, Sharma R, (MDConsult Non- year med residents accessed resourcesShea J. Impact of an medical resources (N=50) randomized to for EBM teachingevidence-based medicine (Google) EBM teaching group or group were Ovid (71%curriculum on resident use control using of residents accessed)of electronic resources: a computer-generated and InfoPOEMsrandomized controlled randomization (62%).study. JGIM: Journal of stratified by level ofGeneral Internal training. Majority of controlMedicine. group accessedNovember;23(11):1804-18 Residents assigned to UpToDate (67%) &08. EBM teaching MDConsult (58%). participated in six 2- hour workshop UpToDate and sessions (12 hours eMedicine do not total) during an consistently use elective month explicit evidence- based processes but Twenty-five residents provide similar were randomized to recommendations for EBM teaching group & patient management 25 to control group as evidence-based resourcesKoonce TY, Giuse NB, 2004 Cochrane 40 complex clinical EBM resourcesTodd P. Evidence-based Database of questions randomly provide answers fordatabases versus primary Systematic selected from in-house general patient caremedical literature: an in- Reviews archival database managementhouse investigation on received by librarians questions moretheir optimal use. J Med HealthGate during clinical rounds frequently than forLibr Assoc. Clinical Guidelines complex clinicalOct;92(4):407-11. Librarian team asked to questions. Results**Librarian study** search UpToDate, showed that EBM Cochrane Database of resources provide Systematic Reviews, more partial answers and HealthGate Clinical for complex CICS Guidelines (formerly, questions than for the EBM Solutions) Pathways questions Librarians established No direct mention of
consensus on whether UpToDate a question was fully or partially answered by one of the resources and instructed to record instances where primary literature was needed to answer question completely.Lucas BP, Evans AT, Reilly 2004 Best Evidence, Pre-post evaluation Attending andBM, Khodakov YV, Medline, resident physiciansPerumal K, Rohr LG, “Searching the have in-hospitalAkamah JA, Alausa TM, literature could access to computersSmith CA, Smith JP. The improve the treatment capable of searchingimpact of evidence on of many medical Best Evidence,physicians inpatient inpatients, including Medline, UpToDate,treatment decisions. J those already receiving and other evidence-Gen Intern Med. evidence-based based resourcesMay;19(5 Pt 1):402-9. treatment…”Patel MR, Schardt CM, 2006 MEDLINE first and Residents randomizedSanders LL, Keitz SA. last search to MEDLINE-first “...UpToDate can beRandomized trial for protocol (protocol A) group costly, ranging fromanswers to clinical searched 120 over $200 perquestions: evaluating a questions, and individual to overpre-appraised versus a residents randomized $40,000 for anMEDLINE search protocol. to the MEDLINE-last institution”J Med Libr (protocol B) searchedAssoc.;94(4):382-7. 133 questions. In protocol A, 104 answers (86.7%) and, in protocol B, 117 answers (88%) were found to clinical questions. In protocol A, residents reported that 26 (25.2%) of the answers were obtained quickly or rated as "fast" (<5 minutes) as opposed to 55 (51.9%) in protocol B, (P = 0.0004). Subset of questions and articles (n = 79) reviewed by faculty who found both
protocols identified similar numbers of answer articles that addressed questions and were felt to be valid using critical appraisal criteriaSchilling LM, Steiner JF, 2005 MEDLINE In 2002, 43 internalLundahl K, Anderson RJ. medicine residents at Most frequently usedResidents patient-specific University of Colorado methods to retrieveclinical questions: outpatient clinic information wereopportunities for answered specific Medline 73%evidence-based learning. clinical questions based (115/158) andAcad Med. on patients seen as UpToDate 70%;80(1):51-6. out-patients (110/158). UpToDate (45%, 71/158) & journals (42%, 66/158) were most helpful; Residents rated impact of information on five point scale (1 = strongly disagree; 5 = strongly agree) for the following: used to assist patient care (mean 4.1), improved care (mean 4.0), improved communication (mean 4.3), improved confidence in care (mean 4.3), improved knowledge (mean 4.6), and improve care for future patients (mean 4.4)Shariff SZ, Bejaimal SA, 2011 UpToDate (92%), Survey looked at how NephrologistsSontrop JM, Iansavichus PubMed (89%), nephrologists use routinely use aAV, Weir MA, Haynes RB, Google (76%) and online information variety of onlineSpeechley MR, Thind A, Ovid MEDLINE sources; cross-sectional resources to searchGarg AX. Searching for (55%) study (2008 to 2010); for information formedical information random sample of patient care. Theseonline: a Canadian include bibliographicsurvey of Canadian nephrologists’ survey databases, generalnephrologists. J Nephrol. of online search search engines and
2011 Feb 23:0. practices; respondents specialized medical revealed search resources. preferences, use of 9 online information sourcesThiele RH, Poiro NC, 2010 Google, Ovid, Medical students, Users of Google andScalzo DC, Nemergut EC. PubMed residents & attending UpToDate were moreSpeed, accuracy, and physicians answered likely than users ofconfidence in Google, four anaesthesia PubMed to answerOvid, PubMed and and/or critical care questions correctlyUpToDate: results of a questions in 5 min,randomised trial. using Google, Ovid, Subjects had mostPostgrad Med PubMed, or UpToDate confidence inJ;86:459-465. (only one search tool UpToDate; searches per Q). After each with Google and search, participants UpToDate were faster rated results on a four than with PubMed or point scale; one to 3 Ovid weeks later, users were randomized to one of 4 search tools to answer eight questions, four of which were repeated
Theme 3: Quality of Hospital and / or Library with access to UpToDate Bonis, Jones n=2 papersStudy authors / journal Date Results MethodsBonis PA, Pickens GT, Rind DM, 2008 Compared US hospitals with online Hospitals withFoster DA. Association of a access to UpToDate with hospitals in UpToDate n=424 hadclinical knowledge support the top 100 Thomson database significantly bettersystem with improved patient performance thansafety, reduced complications “…Hospitals with access to UpToDate other hospitals in theand shorter length of stay (n=424) were associated with Thomson databaseamong Medicare beneficiaries in significantly better performance than n=3-01 on riskacute care hospitals in the other hospitals in the Thomson adjusted measures ofUnited States. Int J Med Inform. database (n=3091) on risk-adjusted pt safety,Nov;77(11):745-53. Epub 2008 measures of patient safety (P=0.0163) complications,Jun 19. and complications (P=0.0012) and had shorter length of stay significantly shorter length of stay (by on average 0.167 days per “Whether UpToDate discharge, 95% confidence interval was a marker of 0.081-0.252 days, P<0.0001). All of quality, an these associations correlated independent cause of significantly with how much UpToDate it or one of several was used at each hospital. Mortality features of hospital was not significantly different between quality that led to UpToDate and non-UpToDate better performance hospitals….” remains unclear.”Jones DA, Poletti EJ, Stephenson 2010 A regional network studied value of Results: mediatedP. Demonstrating the Value of library services by focusing on I. value searching impactsLibrary Services in South Central provided by literature searches II. decision making andVA Health Care Network Medical interlibrary loan through statistics and cost; library costCenters. Journal of Hospital comparisons of commercial costs and benefits, lower costLibrarianship. 2010; 10(3): III. efficiency of electronic resources per use of regional211-23. through cost per use resources. Shows value of library services & role of provision of health information in quality careSee also: Lucas, 2004See also: Schilling LM, Steiner JF, Lundahl K, Anderson RJ. Residents patient-specific clinical questions:opportunities for evidence-based learning. Acad Med. ;80(1):51-6. where Residents rated impact ofinformation on five point scale (1 = strongly disagree; 5 = strongly agree) for the following: used to assistpatient care (mean 4.1), improved care (mean 4.0), improved communication (mean 4.3), improvedconfidence in care (mean 4.3), improved knowledge (mean 4.6), and improve care for future patients(mean 4.4)
Theme 4: Survey of Physician/Librarian Usage of UpToDateChiu, Cooper, Davies (librarian), Dee, Dezee, Edson, Farrell (librarian), Johnson, Lai, Leff, McCord, Peterson, Phua, Peterson, Shariff, Somal, Thun, Wallace, Wandersee, Wheeler (n=20 papers) Type ofStudy authors / Date Physician Resultsjournal Methods OR Librarian Led study?Chiu Y, Weng YH, Lo Physician Structured physician Best -known databases-HL, Ting HW, Hsu CC, 2009 survey survey in Taiwan; 457 MEDLINE (80.1%) and ICPLShih YH, Kuo KN. complete responses. (76.4%), Cochrane LibraryPhysicians Internet-based (49.9%) CEPS (43.8%)characteristics in the resources accessed ProQuest (37.9%), MDusage of online more than personal or Consult (38.1%), anddatabase: a paper ones for clinical UpToDate (36.1%)representative informationnationwide survey of Most accessed- (1) MEDLINEregional hospitals in Asked if they had access (86.2%), (2) Cochrane LibraryTaiwan. Informatics to Index to Chinese (51.2%), (3) ICPL (48.6%), (4)for Health and Social Periodical Literature UpToDate (45.7%), (5)Care. ;34(3):127-135. (ICPL), Chinese ProQuest (43.8%), (6) MD Electronic Periodical Consult (43.3%) and (7) CEPS Services (CEPS), (33.1%). Cochrane Library, MD Consult, MEDLINE, ProQuest & UpToDateCooper AL, Elnicki 2011 Librarian 144 students surveyed Most medical students useDM. Resource Led study UpToDate for physicianutilisation patterns of rounds & admitting (64 andthird-year medical 67%); exam prep; questionstudents. books associated withClin Teach. significant improvement inMar;8(1):43-7. scores (77 vs 72%, p < 0.01).Davies KS. Physicians 2011 Librarian 498 e-mails were Physicians in US (43.8%) andand their use of Led study delivered to US Canada (40.0%) more thaninformation: a survey physicians and 416 to twice as likely to use wirelesscomparison between Canadian physicians. laptops compared to UKthe United States, 80 responses were (18.8%). Canadian (51.3%)Canada and the received from both US and US physicians (41.3%)United Kingdom. J and Canadian more than twice likely to useMed Libr Assoc. physicians, which was a personal digital assistants;99(1):88-91. response rate of 16% (PDAs) compared to UK and 19%, respectively. physicians (16.3%) In UK, 2351 emails were Most-frequently used delivered with 636 subscription-based resources questionnaires were UpToDate & MD completed representing Consult; used more often by a response rate of 27%. physicians from US and
Canada compared to UK. Previous research MEDLINE/PubMed most compares physicians frequently used resource for use of electronic all physicians. resources, MEDLINE features, preferred sources for clinical information, perceived barriers to accessing information for patient care in specific countries, attitudes toward evidence-based medicine (EBM) and understanding of EBM Study compares aspects focusing on EBM resources in Canada, UK & US.Dee KJ, Durning S, 2005 Medical Determines if format Most commonly reportedDenton GD. Effect of students at (electronic or print) or resources were UpToDateelectronic versus print the USU in choice of reading (99%), review or questionformat and different Bethesda materials is associated book (93%), and Harrisonsreading resources on (uniform with knowledge Principles of Internalknowledge services acquisition during 3- Medicine (82%)acquisition in the university) year internal medicinethird-year medicine clerkshipclerkship.Teaching & Learning 114 -3rd-year internalin Medicine. Fall; 17 medicine clerkship(4): 349-54. students participatedDeZee KJ, Durning S, 2005 Medical Prospective cohort UpToDate (99% some useDenton GD. Effect of students study- survey of reading (58% most importantelectronic versus print materials used for resource), review or questionformat and different NBME exam med book (93%, most importantreading resources on students 27%), and Harrison’sknow. ledge Principles of Internalacquisition in the 114 3rd year int med Medicine (82%, mostthird-year medicine students surveyed important 7%).clerkship. Teaching &Learning in Medicine. UpToDate was most useful,Fall; 17 (4): 349-54. then MDConsult then Harrison’sEdson RS, Beckman 2010 Residents Residents at 5 IM 189/413 responses- 77.7% ofTJ, West CP, residencies surveyed on residents reported readingAronowitz PB, reading and learning less than 7 h a week; 81.4%Badgett RG, Feldstein habits and preferences read in response to patientDA, Henderson MC, care encounters.
Kolars JC, McDonaldFS. A multi- Preferred electronic; 94.6%institutional survey of UpToDate most effective forinternal medicine knowledge acquisition; 88.9%residents learning UpToDate first choice forhabits. Med Teach. answering clinical questions2010; 32(9): 773-5.Farrell A. An 2008 Librarian led Survey to CANMEDLIB 5 most used evidence basedevaluation of the five study electronic mail list to tools were BMJ Clinicalmost used evidence identify most frequently Evidence, UpToDate, Firstbased bedside used evidence based Consult, Bandolier & ACPPierinformation tools in bedside informationCanadian health tools; 52 responses out Librarians satisfied with easelibraries. Evid Based of possible 450-500. of use, efficiency &Libr Inf Pract.;3(2):3– informative nature of17. Clinical questions were resources used to measure the comprehensiveness of UpToDate was easiest to use each resource and the & most comprehensive- levels of evidence they provided information for provided to each highest # of clinical question questions, level of evidence only 7% of the timeJohnson PT, Makary 2008 Medical Case cross-over studyMA, Chen JK, Eng J, students at randomly assigned 89 Few students said they usedFishman EK. A Johns medical student UpToDate for detailed,Comparison of World Hopkins volunteers to use either complicated or managementWide Web Resources Google or any other information, relying on otherfor Identifying web-based resource sites (Wikipedia, eMedicine)Medical Information. (excluding Google) to for basic informationAcademic Radiology. research 10 advancedSep medical questions in a “UpToDate is recommended1;15(9):1165-1172. multiple choice exam. by the American Academy of Family Practitioners.” A total of 135 students enrolled, for an initial Despite preferences for response rate of 28% UpToDate, when instructed (135/480) to use resources other than Google to identify medical information, most common tool selected was a search engine (Yahoo, AltaVista) followed by WikipediaLai CJ, Aagaard E, 2006 Medical Participants asked open- 98% of residents reportedBrandenburg S, students ended /5-point Likert using UTD regularly, 44%Nadkarni M, Wei HG, questions about reading literature search, 35% GoogleBaron R. Brief report: habits: time spent or other search enginesmultiprogram reading, preferred
evaluation of reading resources, motivatinghabits of primary care and inhibiting factors Motivating factors wereinternal medicine medical problems ofresidents on 124 second- or third- individual patients andambulatory rotations. year PCIM residents on preparation for presentationsJ Gen Intern Med. ambulatory care2006;21(5):486–9. rotation for at least 7 Inhibiting factors (including days without overnight family / personal call responsibilities responsibilities & lack of motivation) Online-only sources used most often; UpToDate used by almost all respondents; in a shift from early 1990s, when textbooks, journals, and pocket manuals were primary medical resourcesLeff B, Harper GM. 2006 Internal 18-item survey tool to Most commonly used andThe reading habits of medicine 120 students on their useful reading sources weremedicine clerks at one clerkships first inpatient internal UpToDate & test prep textsmedical school: (medical medicine clerkshipsfrequency, usefulness, students) Students spend significantand difficulties. Acad One hundred twelve of time reading online sourcesMed.;81(5):489–94. 120 (93%) medicine during medicine clerkship, clerks completed especially UpToDate survey. Said they read an average of 10.8 Medical educators should be (SD 5.6) hours per week familiar with sources and (median ten hours per contribute to maximizing week, range one to 30 effectiveness for students hours per week)McCord G, Smucker 2007 Family Questionnaire asked 37 44% of questions were foundWD, Selius BA, residents – full-time faculty and by asking attendingHannan S, Davidson medical residents about best physicians, 23% by consultingE, Schrop SL, Rao V, students sources, subscriptions, PDAs; 20% books; 72%Albrecht P. Answering observed why they use PDAs; answered in 2 mins; residentsquestions at the point experience preventing rated UpToDate as bestof care: do residents medical errors source but used it only 5xpractice EBM ormanage information PDAs were used for ease,sources? Acad time, accessibility; errorsMed.;82(3):298-303. discovered or prevented with**good study** PDAs were medication related; no participants required use of specific medical info resourcesPhua J, Lim TK. How 2008 Residents Study evaluated how Only 76 doctors (56.7%) usedresidents and interns and interns residents and interns UpToDate; even thoughutilise and perceive use personal digital hospital had institutional
the personal assistants & UpToDate subscription; 93.4% of usersdigital assistant and recommend UpToDate; onlyUpToDate. BMC Med Questionnaire survey of 57.9% say UpToDate led toEduc. Jul 14;8:39. residents and interns in change in care**good study** tertiary teaching hospitals; out of “.... 93.4% of users 168, 134 (79.8%) recommend UpToDate to responded; 54 doctors colleague, [but] only 57.9% (40.3%) owned PDA; stated use of UpToDate had PDA seen as most useful led to change in management for drug information, of patients...” followed by med references, medcalcsPeterson Phua MW, 2004 Medical Med students adopted 85% identified primaryRowat J, Kreiter C, students on UpToDate as clinical resources (UpToDate 53%,Mandel J. Medical clerkships resource during MDConsult 33%; p <.001students use of clerkships compared to paper; reportedinformation using info resources daily andresources: is the 116 of 154 students required less than 15minsdigital age dawning? (75%) responded to answer most questionsAcad Med.79(1):89-95.Shariff SZ, Bejaimal 2011 Canadian Surveyed search Nephrologists used onlineSA, Sontrop JM, nephrologist preferences, practices sources for patient treatmentIansavichus AV, Weir s and use of 9 online info such as UpToDate (92%),MA, Haynes RB, information sources PubMed (89%), Google (76%)Speechley MR, Thind and Ovid MEDLINE (55%)A, Garg AX. Searching Respondents (n=115;for medical 75% response rate) Community-basedinformation online: a comprised academic nephrologists more likely tosurvey of Canadian (59%) and community- use UpToDate (91%),nephrologists. J based (41%) while academic nephrologistsNephrol. Feb 23. nephrologists; average divided between UpToDate of 48 years old and in (58%) & PubMed (41%) practice for average of 15 yearsSomal K, Lam WC, 2009 Residents Online survey eMedicine used more thanTam E. Computer and and trainees UpToDateinternet use byophthalmologists andtrainees in anacademic centre. CanJ Ophthalmol.Jun;44(3):265-8.Thun AMV, Stephens 2009 Military What sources are Military physicians useMB. Military Medical physicians commonly used by staff Internet to access medicalInformatics: Accessing military physicians, info every day; frequency andInformation survey asked to pattern of use differs if onin the Deployed describe sources of deployment; commonEnvironment. Military medical information sources are general searchMedicine. Mar used engines (Google)
1;174(3):259-264. PubMed & MEDLINE are more commonly used by military surgeons, while filtered secondary sources (UpToDate, MD Consult) used by military primary care physiciansWallace RL. ETSU 2007 Residents & Residents surveyed Residents used Google andmedical residents clinical about use of info ; 217 Web frequently. PubMed wasclinical information faculty residents surveyed, rated as valuable resource;behaviors, 105 returned survey for journals and UpToDate wereskills, training, and return rate of 48% ; important resources forresource use. East clinical faculty surveyed residentsTennessee State in order to measureUniversity. responses of residents against their instructorsWandersee JR. Library 2008 Library Residents didn’t know Reported use of UpToDatecheck-up; medical investigator about library services; was 90% in 2005 and 2006residents and fellows many said they couldlibrary improve searching skills UpToDate and OVID werequestionnaire & wanted training but most popularresponses. Journal of did not attend 1-hourHospital orientation; 65% saidLibrarianship, 2008 they wanted more8(3), 323-331. trainingWheeler TR. 2007 Primary care Information seeking 45% relied on textbooks; 13%Implementation of a providers behaviors by providers; on journals; 28% onmedical knowledge studied to see needs electronic resources asresource in the while seeing patients; primary sources;electronic medical based on patterns questionnaire asked cliniciansrecord -- can more established in literature what e-products used mostclinical questions be based on resources availableanswered at the point 119 respondedof care? J Hosp Why UpToDate? 26 % preferred UpToDate,Librarianship. 1. Users feel answers to 16% PubMed, 13%2007;7(4), 15-29. questions are in UTD Micromedex; 12% UpToDate 2. Access and proximity preferred OVID Medline with (only 1 click away) links to full text 3. Physician champions 4. Intuitive interface (easy navigation) 5. Timeliness: updated regularly 6. Improved speed of network, decreasing wait time
Appendix: Other papers that mention UpToDateJones DA, Esparza J, Duggar DC. Reflecting on the concept of connecting clinicians with library resourcesand librarians through the electronic health record system [abstract]. Medical Library AssociationConference, Washington, DC, 2010.“Objective: To evaluate usefulness of links to selected library resources placed in the electronic healthrecord (EHR) system as perceived by internal medicine residents and to collect statistical data on usage ofthe AskALibrarian link in the EHR.Methods: Through a collaborative effort with computer services, the library now offers links in the EHR to:(1) library resources to aid clinical decision making, (2) the library’s consumer health information (CHI) siteto provide educational materials for patients, and (3) the AskALibrarian service. To build awareness, theseresources and services have been promoted through announcements on the library web page, throughemail messages from computer services, in the institutional and library newsletters, and during morningreport and hospital rounds. Focus groups with internal medicine residents were held to determine theirperceptions about the usefulness of these electronic library resources linked from within the EHR.Participants were consulted on which resources they find most useful in clinical decision making.Additionally, statistics are being collected on the number of questions received through the AskALibrarianlink in the EHR.Results: Most of the residents who participated in the focus groups were aware of at least some libraryresources in the EHR, although none of them reported being aware of healthelinks, the …library’s CHIwebsite. When asked about the most useful resource in the EHR for clinical decision making, UpToDatewas mentioned most often. Some indicated that they like DynaMed because they can access it on theirsmart phones. None of them reported using the AskALibrarian form in the EHR, as supported by usagestatistics. Participants’ responses indicated they preferred personal contact with librarians.Conclusion: The library staff must find additional ways to promote awareness of resources in the EHR andto educate users regarding CHI resources for patients. The library and computer services should replacenonused resources in the EHR with those which clinicians indicate they need…”McDonald FS, Zeger SL, Kolars JC. Factors associated with medical knowledge acquisition during internalmedicine residency. J Gen Intern Med. 2007 Jul;22(7):962-8. Epub 2007 Apr 28.“…UpToDate (Waltham, MA) is a proprietary electronic knowledge resource widely used by trainees andclinicians because of ease of use, broad coverage of multiple topics, and frequent updates.21–24 Thislearning resource was selected as a study parameter for 2 reasons. First, UpToDate is a commonknowledge compendium that is used by many internal medicine residents. A survey of nearly 18,000residents accompanying the IM-ITE in 2003 noted that UpToDate was the most frequently used electronicresource for clinical information (Schultz, October 4, 2005, personal communication). Second, usage of thislearning resource is objectively and quantitatively measurable. To facilitate provision of CME credits,UpToDate tracks usage for each subscriber. Usage data are measured by the amount of time a user islogged on to UpToDate, with a maximum of 10 minutes recorded for any topic per accession. For example,if a topic is accessed for 3 minutes and then the user logs off or accesses another topic within the program,then, measured time for the topic is 3 minutes. If a topic is accessed and then left open for more than10 minutes, the measured time is 10 minutes. Printing a topic review results in 10 minutes of credit.Hence, 1 hour of credit represents reading or printing at least 6 topics.Beginning in May 2002, the Mayo Clinic Internal Medicine Residency, Rochester, MN purchased individualsubscriptions to UpToDate for all of its residents for internet use (see Table 1). Residents were providedwith UpToDate without any expectations of when it should be used or what should be read. Thus, eachindividual resident’s use of the resource was self-directed. Neither the residents nor the investigators knewthat UpToDate use was being electronically tracked before the 2003 IM-ITE. Residents had access toUpToDate for at most 6 months before the 2002 IM-ITE exam and 18 months before the 2003 exam. Noneof the authors have any affiliation with UpToDate nor have they received any financial support fromUpToDate. Other than providing the requested data, UpToDate was not involved in the design of the studynor the analysis of the data.”