A Passion for Evidence

Research opportunities are everywhere on the University of Cincinnati campus, with students and faculty members engaged in investigations that have the potential to save millions of lives.

From her office just off Albert Sabin Way—named for one of UC’s most celebrated researchers—Uma Kotagal, MD, aims to make sure that one opportunity isn’t overlooked: the opportunity to actually put all that research into practice.

"The public assumes that when they come to a physician, they’re getting evidence-based care—in other words, care grounded in knowledge that has been generated from research,” says Kotagal, a member of the senior management team at Cincinnati Children’s Hospital Medical Center and professor of pediatrics and obstetrics and gynecology at UC.

"They don’t realize that there is often a wide gap between research and application.” (A 2003 Rand Corporation study found that only about 55 percent of patients actually received recommended care.)

Kotagal’s titles at Cincinnati Children’s—senior vice president for quality and transformation and executive director, James M. Anderson Center for Health Systems Excellence—give a good indication of the commitment to closing that gap at the hospital.

She’s been an advocate of evidence-based care since receiving her medical degree from the University of Bombay in 1970.

But why does this gap between research and application even exist?

"When researchers are funded to discover new knowledge, they’re often not funded for the next phase of it,” Kotagal says. "They may deliver the answer and give it to a drug company or publish the results, but funding the scalability of the application and the effectiveness studies are not often part of the research. Therefore, it lags.

"Also, it requires reliable systems to deliver the evidence, and our focus with health care in the United States has not been on reliable systems—it’s been on content and knowledge generation and not addressing unwarranted variation.”

Kotagal’s passion for evidence-based care drove her to return to school after two decades as a neonatologist and earn a master’s in epidemiology from the Harvard School of Public Health in 1996.

Since then, she has focused her research on delivery systems and quality improvement and health services research.

Building a Bundle of Interventions

For example, a 2009 study published in the Joint Commission Journal on Quality and Patient Safety focused on efforts at Cincinnati Children’s to reduce surgical site infections, a persistent problem in U.S. health care despite advances in infection control practices such as sterilization methods and improved operating room ventilation.

Led by Frederic Ryckman, MD, and other colleagues, the Cincinnati Children’s improvement team developed and implemented strategies to enhance the number of patients who received timely antibiotic administration, including a surgical site infection-prevention bundle that relied on a collection of evidence-based care processes.

Additionally, monthly reports and annotated control charts were shared with the improvement team and organizational leadership and also posted on the hospital’s patient safety intranet site.

As a result, the surgical site infection rate decreased from 1.5 per 100 procedure days to 0.54, a 64 percent reduction. As the study authors said, it was a matter of making the right thing to do—sharing and examining data, for instance—the easy thing to do.

In quality improvement research, Kotagal points out, the unit of experiment is the system, not the patient.

"We’re interested in asking, ‘If intervention A has been shown to work, how can we do what it takes using quality improvement to reliably apply the evidence?’” says Kotagal. "That’s a very big difference.”

The surgical site infection initiative, for instance, was based on numerous evidence-based articles. "But each paper answered the question about one intervention,” Kotagal says. "When you put all the interventions together in a bundle, you get the much greater reduction in infection.”

Keep on Keeping On

So how do you keep the improvement going? In Kotagal’s view, it’s a matter of continuously raising the bar with the help of new knowledge.

"The key is to design a learning system that allows us to understand and keep continuously learning,” she says. "If you achieve sizable improvement in a multi-site network with a large number of patients and then it plateaus, you have to say, ‘This is how far we can get with the current knowledge. Now I have to go back to the bench or clinical research or comparative effectiveness research to see what works for whom and get segmentation to the next plateau.’

"Each time, you’re answering it for a smaller and smaller sector and getting closer to individual customization.”

In other words, it’s all about matching the right patient to the right therapy. From there, Kotagal says, it’s a matter of making sure the patient adheres to the treatment.

"That’s what we’re trying to do,” she says—"link the medication and the evidence, and then we’re going to use scientific approaches—again—to help patients apply the medication.”

Institute of Medicine

Kotagal is one of nine UC faculty who are members of the Institute of Medicine of the National Academies:

• Eula Bingham, PhD
  Environmental Health (Medicine)
  
• Thomas Boat, MD
  Pediatrics (Medicine)
  
• Robert Graham, MD
  Family Medicine (Medicine)
  
• Jane Henney, MD
  Internal Medicine (Medicine)
  
• Margaret (Peggy) Hostetter, MD
  Pediatrics (Medicine)
  
• Alan Jobe, MD, PhD
  Pediatrics (Medicine)
  
• Uma Kotagal, MD
  Pediatrics (Medicine)
  
• Arnold Strauss, MD
  Pediatrics (Medicine)
  
• Jeffrey Whitsett, MD
  Pediatrics (Medicine)
  

This story was featured in the June 2011 edition of UC Research. Download the full edition (PDF).