“Access to information literally saves lives”: free access to UpToDate in LMICs

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Grace Fletcher

Grace Fletcher

Grace Fletcher is a candidate for the MPH in Global Health & MA in Latin American Studies at Vanderbilt University. She works at the intersection of social science and global health and is interested in research, M&E, and program improvement, especially in marginalized Latin American communities. She is the Editor of the Global Health Hub. @grfletcher07

This week, Yannis Valtis joined us for a short conversation about a new paper he and colleagues recently published in BMJ Global Health. Their study evaluated a program to provide free access to UpToDate to clinicians practicing in low-resource settings, and the findings were fascinating. If you are practicing medicine outside of the United States, the program is ongoing and applications can be filled out here.


Yannis K. Valtis is a medical student at Harvard Medical School and a student collaborator at the Global Health Delivery Project at Harvard University (GHD). At Harvard, Yannis works to improve access to evidence-based clinical information for clinicians and students around the world. Before medical school, Yannis worked for the Boston Consulting Group, where he advised global health institutions, including the Bill & Melinda Gates Foundation and the Ministry of Health of Lesotho. He holds a B.A. in Developmental Biology from Harvard College and is an Alexander Onassis Scholar at Harvard Medical School.


What is UpToDate and why is it a useful tool for clinicians, especially in low-resource settings?

UpToDate is an online evidence-based clinical decision support tool. UpToDate hires experts on thousands of medical topics to write data-driven articles and guidelines on how to diagnose and treat disease. What makes UpToDate special is that authors are expected to keep their information current by reading the literature and incorporating any new evidence into their discussion of a particular disease every few months.

As we discuss in the paper, a large proportion of U.S. clinicians uses UpToDate. Research has shown that  hospitals that use UpToDate in the U.S. have lower mortality than ones that don’t, after you control for other factors. This access to information literally saves lives.

In low-resource settings, clinicians are often asked to practice at the “top of their license.” General internists and primary care physicians are asked to diagnose and treat disease that would fall under the purview of subspecialists in the U.S. This, of course, is due to the extreme lack of medical specialists across many low and middle income countries. As an example, Rwanda, a nation of approximately 11 million people, had until recently a total of 15 anesthesiologists, 25 obstetricians, and zero neurologists. Access to current, valid, and evidence-based information becomes critical when a physician is treating a disease on which they might not have received much formal training.


I was fascinated by the list of most frequently accessed UTD topics by continent. What do you think that tells us about the state of global health generally?

Before we began the analysis, I expected infectious diseases to be at the top of our users’ interests, given the death toll they still exact among populations living in resource-limited settings. To some degree, this is what we found: malaria was the most searched topic in Africa and Hepatitis B the most searched topic in Asia.

Interestingly, however, topics such as heart failure, stroke, diabetes, and hypertension – which we think of as big killers in high-income countries – were extremely popular among clinicians working in low-resource settings. One hypothesis is that noncommunicable diseases are rising in relative prevalence as more countries undergo epidemiological transitions. Another way to look at it is that countries have spent years developing clear and successful guidelines for the treatment of priority infectious diseases such as HIV, malaria, and tuberculosis and thus, doctors don’t need to turn to UpToDate for the answers. Noncommunicable diseases, however, might not have as standardized or well-distributed management guidelines, making a tool like UpToDate particularly useful.


How do you think the UTD program (or a similar information-sharing resource) can be scaled up to reach more clinicians?

I believe it’s important to ask what barriers do clinicians face in accessing the information they need. Cost of subscription to some of these resources is one key factor and we showed that when you remove it, a large number of clinicians will use UpToDate frequently. However, there are other barriers: the high cost of internet connections, the lack of training on use of clinical information resources, and of course, many of those resources have been written primarily for clinicians practicing in rich or English-speaking settings.

Incorporating clinical resources in medical education, lowering the cost of internet through deals with local internet providers, and developing content that is particularly relevant for those practicing in resource-limited settings are the key steps to maximizing the impact of clinical resources.

Click here to learn more about the UpToDate program and apply for free access.