All topics in UpToDate are written by the listed authors in
conjunction with a deputy editor. Authors are identified as experts by the
Editors-in-Chief, our editorial staff, and the participating societies.
Exceptions are guidelines from major societies, which are added to UpToDate
in their original form. All material is originally prepared by the contributing
author(s) whose name(s) and affiliation(s) appear in the upper left corner of
each topic. This material is reviewed extensively by our physician editors
and peer reviewers for accuracy and completeness of the literature search, and
for consistency with all aspects of the editorial policy. Physician editors
suggest changes to ensure that the topics summarize the relevant evidence, and
that the recommendations are consistent with the evidence, with our understanding
of patients' values and preferences, and with UpToDate's editorial policy. Some
of the content may be taken from other topics in UpToDate. In such cases,
the text is hyperlinked to the topic from which it originated.
Occasionally, authors of a particular topic are replaced. A new author is required
to thoroughly review the topic and make necessary revisions, but is not required
to completely rewrite the topic. The revised topic undergoes the same peer review
process as new topics in the program.
Evidence
UpToDate follows a hierarchy of evidence consistent with most evidence-based
resources. At the top of the hierarchy are randomized trials of high methodological
quality, followed by randomized trials with methodological limitations, observational
studies, and unsystematic clinical observations. Inferences are stronger when
the evidence is summarized in systematic reviews of the literature that present
all relevant data.
Each topic has an author who is an expert in the area discussed, and at least two
separate physician reviewers. This group works together to perform a comprehensive
review of the literature and carefully select studies for presentation based upon
the quality of the study, the hierarchy of evidence discussed above, and clinical
relevance. When current, high-quality systematic reviews are available, UpToDate
topics and recommendations rely heavily on these reviews. When such reviews are
unavailable, UpToDate summarizes the key studies bearing on the clinical issues at
hand. Systematic reviews and the design of primary studies (randomized trial,
observational studies) are often identified explicitly in the text, with the
relevant data. However, in cases where either the type of study or the data are
not stated explicitly, users can click on the reference and bring up the Medline
abstract to obtain this information. Evidence is derived from a number of resources,
including but not limited to:
Electronic searching of databases including MEDLINE, The Cochrane Database,
Clinical Evidence, and ACP Journal Club
Guidelines that adhere to principles of evidence evaluation described above
Published information regarding clinical trials such as reports from the
Food and Drug Administration, as well as other sources of information produced
by federal agencies such as the Centers for Disease Control and Prevention
and the National Institutes of Health
Proceedings of major national meetings
The clinical experience and observations of our authors, editors, and peer
reviewers
Recommendations
Structured Questions
UpToDate's process of arriving at recommendations involves constructing
a structured clinical question. That structure includes carefully defining
the patient population of interest, the alternative management strategies,
and the outcomes of importance to patients.
Values and Preferences
A fundamental principle of evidence-based medicine, as described by Dr. Gordon
Guyatt from McMaster University, is that "Evidence alone is never sufficient
to make a clinical decision. Decision makers must always trade the benefits
and risks, inconvenience, and costs associated with alternative management
strategies, and in doing so consider the patient's values" [1].
This principle has led some evidence-based resources to avoid making specific
recommendations for patient care, since the recommendation needs to account
for all of the factors cited. UpToDate has taken a different approach. It is
the policy of UpToDate to make specific recommendations for patient care whenever
possible. Recommendations in UpToDate are based upon a synthesis of evidence
including that from clinical trials and clinical experience; whenever possible,
the evidentiary basis for recommendations is stated explicitly. When there
is no published systematic evidence available (eg, prednisone dosing regimen
in pulmonary sarcoidosis), recommendations are based upon the unsystematic
clinical observations of our experts and reviewers, and on pathophysiologic
rationale.
UpToDate recommendations identify situations in which different decisions might
be appropriate for patients with different values and preferences. Furthermore,
UpToDate recognizes that recommendations will not apply to every patient, and
counts on clinicians to evaluate the recommendations in light of the individual
circumstances of their patient. Nevertheless, UpToDate feels that giving clinicians
access to recommendations based on a sophisticated understanding of the clinical
issues, the best evidence, and a consideration of patient values and preferences,
allows them to make informed decisions with and for their patients.
As discussed below, UpToDate commonly uses the terminology "we recommend..." or "we suggest..." when describing recommended courses of action, since recommendations generally reflect a consensus of the author(s) and editors of a topic. When there are disagreements, although these same wordings are used, the recommendations are those of the author(s), and the disagreement among experts is discussed within the text. If other topics in UpToDate make alternative recommendations, those topics and recommendations are hyperlinked.
Grading
UpToDate began grading recommendations for treatment and screening in 2006.
This is a continuing process, and not all such recommendations have yet been
graded. Graded recommendations appear in the Summary and Recommendations
sections at the end of topics.
UpToDate uses the UTD-GRADE format, a modification of the GRADE system [2,3].
Grades have two components, a number (1 or 2) reflecting the strength of the
recommendation and a letter (A, B, or C) reflecting the quality of the evidence
supporting that recommendation.
A Grade 1 recommendation is a strong recommendation to do (or not do) something,
where the benefits clearly outweigh the risks (or vice versa) for most, if
not all patients. A Grade 2 recommendation is a weaker recommendation, where
the risks and benefits are more closely balanced or are more uncertain. The
majority of recommendations will be grade 2 recommendations. UpToDate uses
a wording that reflects the strength of the recommendation: strong (Grade 1)
recommendations are "recommended" and weak (Grade 2) recommendations
are "suggested".
Grade A evidence means high-quality evidence that comes from consistent results
from well-performed randomized controlled trials, or overwhelming evidence
of some other sort (such as well-executed observational studies with very strong
effects). Grade B evidence means moderate-quality evidence from randomized
trials that suffer from serious flaws in conduct, inconsistency, indirectness,
imprecise estimates, reporting bias, or some combination of these limitations,
or from other study designs with special strength. Grade C evidence means low-quality
evidence from observational evidence, or from controlled trials with several
very serious limitations.
Additional detailed information about the UTD-GRADE
system is available for those interested in learning more about how we
apply evidence grades and for those who wish to use the system.
Grading recommendations involves subjective judgments about evidence, benefits,
and harms. Users of UpToDate are welcome to communicate concerns about grades
to the editorial staff.
Moving from Evidence to Recommendations
The following table presents the criteria that UpToDate authors and editors
consider when weighing the advantages and disadvantages of treatments to decide
on a recommendation, and grade the strength of that recommendation.
Issue (and what should be considered)
Recommended process
Quality of evidence
Strong recommendations usually require high-quality
evidence for all the critical outcomes. The lower the quality of evidence,
the less likely a strong recommendation.
Relative importance of the outcomes (benefits, harms, burdens)
Authors and editors consider the relative values and preferences that
patients and other stakeholders place on outcomes and the variability
in values and preferences across patients. If values and preferences
vary widely, a strong recommendation becomes less likely.
Baseline risks of adverse outcomes (typically most relevant for benefits)
The higher the baseline risk of an adverse outcome, the greater the
magnitude of benefit from a treatment, and the more likely a strong recommendation.
If the baseline risk is very different for two subpopulations, then UpToDate
may make separate recommendations for these different populations.
Magnitude of effect (benefits - eg. reduction in RR; harms - eg. increase
in RR; burden)
Larger relative risk reductions with treatment make a strong recommendation
for treatment more likely, while larger increases in the relative risk
of harms make a strong recommendation for treatment less likely.
Absolute magnitude of the effect (benefits, harms, burden)
The larger the absolute benefits with treatment, the greater the likelihood
of a strong recommendation in favor of treatment. The larger the absolute
increase in harms, the less likely a strong recommendation in favor of
treatment.
Precision of the estimates of the effects (benefits, harms and burdens)
The greater the precision, the more likely a strong
recommendation.
Cost
The higher the incremental cost, the less the likelihood of a strong
recommendation in favor of a treatment.
Updating
UpToDate performs a continuous comprehensive review of the resources listed
above to keep the program updated. All of the topics in UpToDate are
revised whenever important new information is published, not by any specific
time schedule. Updates are integrated carefully, with specific statements
as to how the new findings should be applied clinically. Each topic
has a date indicating the most recent time the topic has been reviewed and/or
modified. On average, approximately 40 percent of the topics are updated
during each four-month cycle. A subset of updates added during each four-month
cycle can be viewed by clicking on What's New on the toolbar and selecting
the What's New topic for your area of interest. These represent, according
to our editors, the most important new updates added during the previous
four months.
Peer review
The Deputy Editor for a specialty, as well as the Editor-in-Chief and/or Section
Editors assigned to a topic, review the entire UpToDate content, including
all new topics, updates, and recommendations. In addition, each UpToDate specialty
has assembled a group of peer reviewers, often in conjunction with a sponsoring
specialty society, who are responsible for reviewing selected topics in each
specialty. Finally, any comments from users of UpToDate are formally addressed
with changes made as necessary.
Policy review
UpToDate's policies and procedures are continuously reviewed in consultation
with our Evidence-Based Medicine Advisory Group. Members of this group include
Dr. Gordon Guyatt and Dr. Roman Jaeschke from McMaster University, Dr. Holger
Schünemann from the Italian National Cancer Institute in Rome/McMaster
University, and Dr. Yngve Falck-Ytter from Case Western Reserve University.
Guyatt, G, Rennie, D. Users' guide to the medical literature. Essentials
of evidence-based practice. USA: AMA Press; 2002.
GRADE working group. Grading quality of evidence and strength of recommendations.
BMJ 2004; 328:1490.
Guyatt, G, Gutterman, D, Baumann, MH, Addrizzo-Harris D, et al. Grading
strength of recommendations and quality of evidence in clinical guidelines:
report from an American college of chest physicians task force. Chest 2006;
129:174.
Policies
