Full disclosure: I was an Society of General Medicine UpToDate reviewer several years ago and received a free subscription to UpToDate for my services.  I use UpToDate regularly also (through my institution library).

Amber and colleagues published an unfortunate finding this week in the Journal of Medical Ethics. They found that UpToDate seems to have some issues with conflicts of interest by some of its authors and editors.

UpToDate makes this claim on its Editorial subpage: “UpToDate accepts no advertising or sponsorships, a policy that ensures the integrity of our content and keeps it free of commercial influences.” Amber and colleagues findings would likely dispute that the content is “free of commercial influences”.

Amber and colleagues reviewed the Dynamed and UpToDate websites for COI policies and disclosures. They only searched a limited number of conditions on each site (male sexual dysfunction, fibromyalgia, hypogonadism, psoriasis, rheumatoid arthritis, and Crohn’s disease) but their reasoning seems solid: treatments of these entities can be controversial (for the 1st 3) and primarily involve biologics (last 3).  It seems reasonable that expert opinion could dominate recommendations on male sexual dysfunction, fibromyalgia, hypogonadism and that those experts could be conflicted. (Editorial side note: Few doctors recommend stopping offending medications or offer vacuum erection devices instead of the “little blue pill”. Most patients don’t even realize there are other treatments for ED other than “the little blue pill” and its outdoor bathtub loving competitor!- but I digress). The biologics also make sense to me because this is an active area of research and experts writing these types of chapters could get monies from companies either for research or speaking.

What did they find? Both Dynamed and UpToDate mandate disclosure of COIs (a point I will discuss later). No Dynamed authors or editors reported any COIs while quite a few were found for UpToDate. Of the 31 different treatments mentioned for these 6 topic areas evaluated for 14 (45%) of them the authors, editors, or both received grant monies from the company making the therapies mentioned. Similarly 45%  of authors, editors, or both were consultants for companies making these therapies.  For 5 of the 31 therapies authors or editors were on the speakers bureaus for the companies making these therapies. What’s most worrisome is that both the authors and editors were conflicted for the psoriasis chapter. Thus there were no checks and balances for this topic at all!

From blackbeltbartending.com

While finding COIs is worrisome it doesn’t mean that the overall quality of these chapters was compromised nor that they were biased. We don’t know at this time what effect the COIs had. Further study is needed. Unfortunately, this is probably just  the tip of the iceberg. Many more chapters probably suffer from the same issues. Furthermore, traditional textbooks likely have the same problems.

Disclosing COIs is mostly useless. Disclosure doesn’t lessen their impact.  I don’t understand why nonconflicted authors can’t be found for these chapters.  Do we care so much about who writes a chapter that we potentially compromise ethics for name recognition? Those with COIs should not be allowed to write a chapter on topics for which they have a conflict. Period. If UpToDate is so intent on having them maybe they could serve as a consultant  to the authors or a peer reviewer but even that is stretching it. What really bothers me is that the editors for some of these chapters were also conflicted thus leaving no check on potential biases. As Amber and colleagues point out, even though these chapters underwent peer review what do we know about the peer reviewers? Did they have any COIs. Who knows.

So what should all you UpToDate users do? I suggest the following:

1. Contact UpToDate demanding a change.  They have the lion’s share of the market and until they lose subscribers nothing will likely change.
2. Check for COIs yourself before using the recommendations in any UpToDate chapter. You should be especially wary if the recommendation begin with “In our opinion….”.  (An all too often finding)
3. Use Dynamed instead. It has a different layout format than UpToDate but is quicker to be updated and it seems less conflicted. And its cheaper!