The Better Evidence program at Ariadne Labs has been leading research to better understand the impact that an evidence-based clinical resource can have on front line care.
Study results: BMJ Open, Better evidence: prospective cohort study assessing the utility of an evidence-based clinical resource at the University of Rwanda August 2019
In American medical schools, a historical focus on memorization is giving way to knowing how to find information, synthesize it, and apply it clinically. Evidence-based clinical resources (EBCRs) have the potential to help clinicians improve diagnostic and therapeutic accuracy. However, many EBCRs are subscription based, and their cost is prohibitive for most clinicians and trainees in low-income and middle-income countries.
In the first study to link usage of online educational resources to performance in medical school examinations in Africa, medical students and faculty at the University of Rwanda were offered free access to UpToDate, a leading evidence-based clinical resource. The impact was assessed through two student surveys and their grades.
What did we learn?
- Over 92 percent of Rwandan medical students have an internet-ready device, capable of accessing UpToDate, but the $299 price tag of a subscription is very costly in a country that spent $52 per capita on healthcare in 2014.
- In 2014, the paper authors were able to form an agreement with Wolters Kluwer, the UpToDate parent company, to provide free subscriptions to medical students in Sub-Saharan Africa. Fifty-six percent of the 980 medical students and 29 percent of the faculty invited to enroll did so. About 88 percent of eligible final year students enrolled.
- Researchers precisely tracked online usage of UpToDate; enrolled final year students viewed on average 1.24 cases per day and continued to use UpToDate after graduating.
- After UpToDate access was granted, the Rwandan graduating medical students exam grades– in internal medicine, pediatrics, obstetrics and gynecology and surgery – rose from 68 to 75, and students reported decreased use of Wikipedia.
Overall, the findings suggest that removing the subscription cost barrier can generate an uptake of digital EBCR use among East African medical students and, subsequently, better exam grades. The researchers caution, however, that while UpToDate may have helped students prepare for their exams more efficiently and increase their knowledge base, it is also possible that the exams in 2016 and 2017 were easier than those of years past or that the students were independently academically superior to the previous classes. Future research might explore other digital health tools and features that impact uptake and utility.
Study results: BMJ Global Health, 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, 2016.
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 US 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 (now known as Better Evidence) collaborated with UpToDate to provide free subscriptions to qualifying health workers in resource-limited settings.
Our research evaluated the UpToDate usage patterns of health workers receiving free subscriptions.
What did we learn?
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. While clinicians sought evidence-based information across a wide spectrum of topics, search patterns generally 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.
- Removing the cost barrier to accessing UpToDate leads to frequent use of the resource by a large and diverse set of clinicians practising in low- and middle-income countries.
- Access to evidence based clinical resources for clinicians in all settings is an important component of improved health care delivery. Enhancing access may include removal of cost barriers as well as technological barriers, such as Internet connectivity.
- Policy should support the development and production of EBCR content specific to LMIC health priorities to ensure relevancy and utility.