Table of contents
UpToDate provides expert guidance in over 25 medical specialties and subspecialties. Each specialty is developed and maintained under the supervision of at least one editor-in-chief in conjunction with the in-house physician editor(s) (ie, deputy editor). The editor-in-chief is a recognized world-renowned expert clinician in their specialty and assists in the creation of a table of contents for the specialty. The table of contents is developed with the breadth and depth to serve the needs of both the specialist and nonspecialist. The table of contents is continuously reviewed with topics added or removed as the field evolves.
The specialty editor-in-chief identifies and recruits section editors to oversee sections within the specialty. These section editors are expert clinicians within the subspecialty field. They identify expert clinicians to serve as topic authors, provide detailed reviews of topics, and help develop and maintain the table of contents in their subspecialty. UpToDate contributors are comprised of the specialty editors-in-chief, section editors, authors, and peer reviewers.
All topics in UpToDate are written and maintained by the listed author(s) in conjunction with the listed in-house physician editor(s) (ie, deputy editor) and section editor(s). Authors are recognized expert clinicians in the subject area selected by the section editors and in-house editors.
All authors and other contributors undergo a conflict of interest evaluation designed so that our content remains impartial and unbiased. The name(s), affiliation(s), and disclosures of contributors appear on each topic.
All written material is required to be originally prepared by authors and other contributors. This material is reviewed extensively by our in-house physician editor(s) and section editor(s) for quality and consistency with all aspects of the editorial policy. Physician editors suggest changes so that topics clearly answer common questions, provide clinical guidance, and summarize the relevant evidence. Our internal grading team also reviews recommendations so that they are clear and consistent with the relevant evidence.
UpToDate is updated and published continuously, rather than publishing according to a specific schedule. Editors at UpToDate perform a continual review of peer-reviewed journals, clinical databases, and other resources, and topics in UpToDate are revised to reflect new information that becomes available. Updates are integrated carefully, with extensive review by our expert contributors to help provide context and clinical guidance.
Important and practice-changing updates, in addition to appearing in a traditional UpToDate topic, are highlighted in our "What's New" section and in a topic called "Practice Changing UpDates." Practice Changing UpDates highlight selected updates that may have significant and broad impact on practice.
Topics in UpToDate undergo regular review by our expert contributors. Some are also selected for more substantial revision so that they continue to address the relevant clinical questions and meet editorial standards for quality, clarity, and usability.
Multiple layers of review
All UpToDate content undergoes several layers of internal and external review so that it addresses the relevant clinical questions; meets editorial standards for quality, clarity, and usability; and is free from commercial bias. All new topics and subsequent revisions are reviewed by the author(s), in-house physician editor(s) (ie, deputy editor), and section editor(s). In addition, each UpToDate specialty has assembled a group of reviewers responsible for anonymous peer review of selected topics in each specialty. Finally, any comments from users of UpToDate are reviewed and addressed, with changes or additions to topics incorporated as necessary.
Use of Generative Artificial Intelligence, including Large Language Models
UpToDate content is created based on the latest medical literature and the knowledge and expertise of world-class physicians. Authors, section editors, editors-in-chief, internal editorial staff, and peer reviewers are not permitted to use generative artificial intelligence, including large language models, to create or maintain UpToDate content. This policy serves to promote the creation and maintenance of original UpToDate content and reflect editorial standards for quality, transparency, and clarity.
Additional content types
Our in-house physician editors (ie, deputy editors) work with our authors and section editors to create additional content types synthesized from UpToDate topics that have been developed in accordance with the above policies. Examples of these additional content types include UpToDate Pathways, Lab Interpretation topics, and Key Points Panels.
These content types are linked to the underlying UpToDate topics within our editorial system. A revision or update to a relevant section in an UpToDate topic will generate a simultaneous review and revision of these additional content types as needed. These additional content types directly reflect the content within the underlying topics, and the underlying evidence is explicitly available in the linked topics.
UpToDate summarizes the available medical evidence relevant to each topic and follows a hierarchy of evidence consistent with most evidence-based resources. At the top of the hierarchy are meta-analyses of randomized trials of high methodological quality, followed by individual randomized trials and those with methodological limitations. Observational studies and unsystematic clinical observations provide evidence that is considered lower quality. Inferences are stronger when the evidence is derived from higher-quality studies.
Each topic has an author(s) who is expert(s) 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 on the quality of the study, the hierarchy of evidence discussed above, and the study's clinical relevance. When current, high-quality systematic reviews and/or meta-analyses are available, UpToDate topics and recommendations may rely on these reviews. When such reviews are unavailable, UpToDate cites and summarizes the key studies bearing on the relevant clinical issues. Systematic reviews and primary studies (eg, randomized trials, observational studies) are identified in the text, with the relevant data provided. Users can also review the Medline abstract to obtain additional information by clicking on the reference.
Evidence is synthesized from many resources, including but not limited to:
- Continuous review of over 420 peer-reviewed journals
- Electronic searching of databases, including Medline and Cochrane Library
- Guidelines that adhere to the principles of evidence evaluation described above
- Published information regarding clinical trials, such as reports from the US Food and Drug Administration (FDA), clinicaltrials.gov, and the European Medicines Agency, as well as other sources of information produced by governmental and nongovernmental agencies such as the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO)
- Proceedings of major national and international scientific meetings
- The clinical experience and observations of our authors, editors, and peer reviewers
UpToDate's process of arriving at recommendations involves constructing structured clinical questions. That structure includes carefully defining the patient population of interest, the alternative management strategies, and the outcomes of importance to patients (PICO format: Population, Intervention, Comparators, Outcomes).
Recommendations in UpToDate are based on a synthesis of evidence, including that obtained from clinical trials as well as clinical experience; the evidentiary basis for recommendations is stated explicitly. When there is no published systematic evidence available, recommendations are based on the unsystematic clinical observations of our experts and reviewers and on pathophysiologic rationale. Some evidence-based resources avoid making specific recommendations for patient care when high-quality studies are lacking. UpToDate has taken a different approach. It is the policy of UpToDate to make specific recommendations for patient care whenever possible based on the rationale above.
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 Expertise is thus required to move from evidence to recommendations.
UpToDate recommendations identify situations in which different approaches might be appropriate based on specific patient characteristics and/or patient preferences. Because a recommendation may not apply to every patient, UpToDate relies on clinicians to evaluate the recommendation in light of the patient's individual circumstances. By providing recommendations based on a sophisticated understanding of the clinical issues, the best evidence, and a consideration of patient preferences, UpToDate helps clinicians make informed decisions with and for their patients.
As discussed in the following section, 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. In cases where authors or editors differ in their approach, a primary recommendation is typically made using the same wording, but alternative approaches along with the reasoning behind those approaches are discussed within the text.
UpToDate grades recommendations for treatment and screening. This is a continuing process, with new graded recommendations added on an ongoing basis. In addition, the thousands of existing graded recommendations in the program are regularly reviewed and updated as new evidence becomes available. Graded recommendations appear at the end of topics in the Summary and Recommendations sections.
UpToDate uses the GRADE system.2 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 (or certainty) of the evidence supporting that recommendation.
A Grade 1 recommendation is a strong recommendation to do (or not do) something and is made when the benefits clearly outweigh the risks (or vice versa) for most, if not all, patients. A Grade 2 recommendation is a weaker recommendation and is made when risks and benefits are more closely balanced or are more uncertain. Most recommendations are 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 refers to high-quality (certainty) evidence that comes from consistent results from well-performed randomized trials or other overwhelming evidence (such as well-executed observational studies with very strong effects). Grade B evidence refers to moderate-quality (certainty) evidence from randomized trials that have limitations in conduct, inconsistency, indirectness, imprecise estimates, reporting bias, or some combination of these, or from other study designs. Grade C evidence refers to low-quality evidence from observational evidence or from controlled trials with several very serious limitations.
Additional detailed information about the GRADE system, including an online grading tutorial, 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 using the feedback system that can be accessed from every topic.
The following table presents the criteria 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 at least moderate-quality evidence for all the critical outcomes. The lower the quality of evidence, the less likely there should be 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)
|When the baseline risk of an adverse health outcome is high, the absolute magnitude of benefit from an effective treatment is more likely to be substantive. In this case, a strong recommendation for treatment may be made. If the baseline risk differs for two subpopulations, then UpToDate may make a strong recommendation for one group and a weak recommendation for another.|
|Magnitude of effect (benefits - eg,
reduction in relative risk [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,
|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 there should be 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 there should be a strong recommendation.|
|Cost||The higher the incremental cost, the lower the likelihood of a strong recommendation in favor of a treatment.|
UpToDate's policies and procedures are continuously reviewed and updated as necessary.
- Guyatt GH, Rennie D, Meade MO, Cook DJ. Users' Guides to the Medical Literature: A Manual for Evidence-based Clinical Practice, 3rd ed, McGraw-Hill, New York 2015.
- Guyatt GH, Oxman AD, Vist GE, et al, for the GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336:924.
This policy last reviewed on October 2, 2023.