UpToDate: a comprehensive clinical database

Journal of Family Practice, Sept, 2003 by Gary N. Fox, Nashat S. Moawad

How many clinical questions arise during an average day at the office? How many more questions might one entertain if clear-cut, expert advice were seconds away? Enter UpToDate, an electronic clinical database for, well, acquiring up-to-date clinical information--plus continuing medical education (CME) credits and patient handouts.

Unlike a textbook, UpToDate is not set up for paging through content from beginning to end. Rather, if is designed for searches that yield lists of relevant monographs. UpToDate's initial screen displays simple menu bars and a prominent search box (Figure 1). The next step allows one to narrow the search (Figure 2).

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Per its educational objectives, UpToDate provides "instant access to the most current clinical information and recommendations on patient care and treatment," yet is "comprehensive" from "physiological concepts through results of the most recent clinical trials and protocols." Each monograph indicates when the literature was last reviewed and the document updated. The service is available in 3 formats: personal computer-based, online, and Pocket PC. We reviewed these formats using Windows PCs.

* TESTING UPTODATE IN A CLINICAL CONTEXT

Following are a few questions that needed answering during a half-day of practice:

* How effective is topical terbinafine (Lamisil) in treating Candida skin infections?

* What is a reasonable algorithm to determine the cause of chronic renal failure?

* How does one compound nitroglycerin ointment to treat an anal fissure?

* What is the latest thinking on interstitial cystitis?

* What is the preferred empiric antibiotic therapy for presumed bacterial conjunctivitis in adults?

* Does efficacy differ between injectable and intranasal forms of calcitonin for relief of pain from osteoporotic vertebral compression fractures in postmenopausal women?

UpToDate answered 4 of the 6 questions quickly, requiring no more than a few minutes for each search. We found that 2% nitroglycerin must be diluted to 0.2% for use on anal fissures. We also obtained summarized information on interstitial cystitis, a treatment recommendation for conjunctivitis, and data regarding the efficacy of calcitonin administered by either of 2 routes. The information generally was excellent.

More difficult searches

Testing UpToDate further, we searched for less common maladies. We found 4 sentences on proctalgia fugax that, remarkably, seemed to cover the topic adequately. Transient global amnesia was covered tersely (3 sentences) but, again, adequately. Restless legs syndrome was covered well, in several paragraphs, although drug therapies were discussed in random order rather than by drug of choice. Piriformis syndrome was covered inadequately, and presbyesophagus was hot listed at all.

Controversial topics

Subsequent searches yielded excellent discussions on controversial topics. Many monographs lend themselves best to leisurely reading, but they could also be used at the point of care. For example, the controversial diastolic "J-curve phenomenon" in treating hypertension is covered in about fourteen 2- to 6-sentence paragraphs. A summary appears first, typical of UpToDate's style (Figure 3).

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This section on diastolic blood pressure is subdivided into "Positive studies," "Negative studies," and the "HOT trial." Users may jump directly to the "HOT trial" summary by clicking on that title on the left window. References appear in a text box at the bottom of the screen. The relative sizes of these 3 windows may be changed by grabbing and dragging the lines dividing them.

Drug mentions

Drugs mentioned in UpToDate are hot-linked to the corresponding Lexi-Comp drug information monograph, which is "intended to serve as a rapidly accessible, concise initial [drug] reference resource." UpToDate/Lexi-Comp does hot provide guidance regarding cost of drug therapies.

* NOTABLE FEATURES

Graphics

When the user clicks on a graphic's link in the text, a figure, table, or picture is superimposed on the text. The image disappears when the user returns to the text.

Patient education handouts

UpToDate offers patient education handouts; however, these could be made much more accessible. Veteran users know exactly where to look for these handouts, but novices may apply the "3 clicks and you're out" rule when the process proves too frustrating.

Both "Prostate Cancer Screening" (including PSA testing) and "Screening for Breast Cancer" (including mammography) are about 5 single-spaced pages long when printed using Times New Roman 12-point. Although controversies are covered well, out guesstimate of the reading comprehension level is 1 or 2 years post-high school--maybe too difficult for patient education.

Search engine

UpToDate's search engine is rudimentary. Multiword medical term searches are supported (eg, "chronic renal failure" and "vertebral compression fracture"), as are initial word fragments (eg, "spondyl). However, searches incorporating Boolean operators (AND, OR, NOT) and unrelated words are not directly supported, although an obtuse "secondary search" does provide for one AND operation. On this secondary search screen, users may choose to focus on a specific category of information, such as diagnosis, treatment, pathogenesis, or patient information.