Veterinary: Finding the right direction
December 31, 2012
By Katie Burns
Preventive medicine. Cardiopulmonary resuscitation. Euthanasia. These are just some of the topics of new clinical guidelines that could improve outcomes in veterinary medicine.
For practitioners, the real question is whether and how to implement the various guidelines that come out each year. The answer lies in examining guideline sources and adapting the recommendations to suit each situation.
Dr. Douglas G. Aspros, AVMA president and a partner at three animal hospitals in New York state, believes guidelines are aimed at “making us better practitioners in an otherwise messy world of clinical practice.”
Veterinary groups that develop clinical guidelines are starting to shift from a reliance on expert opinion to more of an emphasis on evidence-based medicine, said Dr. Brennen McKenzie, president of the Evidence-Based Veterinary Medicine Association and a practitioner at Adobe Animal Hospital in Los Altos, Calif.
“I think guidelines serve a really important purpose in terms of evidence-based medicine being a practical, pragmatic tool,” Dr. McKenzie said. “Practitioners realistically are not going to have the time to locate and critically appraise the literature in detail on their own on a real-time basis.”
The Evidence-Based Veterinary Medicine Association supports guidelines that are based on controlled research and developed through a transparent process, he said.
As an example, Dr. McKenzie pointed to the new guidelines for CPR in cats and dogs from the Reassessment Campaign on Veterinary Resuscitation, a collaborative effort of the American College of Veterinary Emergency and Critical Care and the Veterinary Emergency and Critical Care Society.
Participants in the RECOVER initiative graded the evidence for each recommendation, acknowledging when they had to rely on expert opinion rather than research.
The new guidelines on preventive care for cats and dogs from the AVMA and American Animal Hospital Association draw on existing guidelines but do not spell out the evidence for each recommendation, such as the recommendation for annual veterinary visits.
“If we are going to recommend them, we need to at least be clear about the level of evidence behind that, which may simply be common sense or clinical experience rather than research evidence,” Dr. McKenzie said. “Ideally, we need to make an effort to validate that recommendation in some more objective way.”
One of the co-chairs of the RECOVER initiative is Dr. Dan Fletcher, an assistant professor of emergency and critical care at Cornell University College of Veterinary Medicine. He said CPR protocols have improved outcomes in human medicine, and RECOVER participants saw a corresponding opportunity in veterinary medicine.
Dozens of veterinarians evaluated relevant literature, providing input for the RECOVER co-chairs to use in drafting guidelines on CPR in cats and dogs. The co-chairs integrated comments from the RECOVER committee and the general membership of a number of veterinary specialty groups before publishing 101 recommendations in June 2012.
“We’ve met with a lot of very positive reaction to this whole process and to the guidelines we were able to develop,” Dr. Fletcher said. “In veterinary medicine, we’ve struggled for a long time to get hold of things that we can be really confident are the right things to do for our patients.”
The next step is to provide training on the CPR guidelines. The guidelines are the subject of one of the first courses through Veritas—a new source of online continuing education from Cornell, Texas A&M University, and Pfizer Animal Health. The guidelines also will be the subject of an in-person, hands-on course from the American College of Veterinary Emergency and Critical Care.
Dr. Fletcher added, “One of the real goals of this process was to identify the big knowledge gaps. So, where are the places we don’t have good evidence to make recommendations?”
For each of 87 clinical questions that they examined to develop the guidelines, the RECOVER participants offered not only a conclusion and a summary of the evidence but also a summary of the knowledge gaps.
ACVIM consensus statements
The American College of Veterinary Internal Medicine develops consensus statements on the state of current knowledge for difficult or controversial topics in small and large animal medicine, said Dr. Rance Sellon, a member of the ACVIM Board of Regents and an associate professor of small animal medicine at Washington State University College of Veterinary Medicine.
The ACVIM has established procedures for choosing topics for consensus statements, empaneling experts to develop the statements, and allowing input from diplomates.
Dr. Leah Cohn, ACVIM chair and a professor of small animal internal medicine at the University of Missouri-Columbia College of Veterinary Medicine, said, “The ACVIM supports the practice of evidence-based clinical medicine to the degree possible.” She said if discussion were limited to only those topics of importance to veterinary medicine that can be supported by the best quality of evidence, there would be little to present. Consensus statement panels “prepare a document that reflects evidence—and may discuss the strength of the evidence—and offers expert opinion when appropriate.”
Dr. Cohn believes well-developed guidelines can be a useful tool for veterinarians. She said, “While medical decisions should never be made by rote following any sort of checklist or guideline document, these tools can promote best practices and help in clinical decision making.”
The AVMA develops fewer clinical guidelines than many specialty or species groups do, although many of the Association’s policies have to do with the practice of veterinary medicine.
The Association has provided research-based guidelines on euthanasia since the 1960s. A five-member panel wrote the first report on the subject. Eleven working groups developed and integrated comments into the newest guidelines, soon to be available.
The AVMA and AAHA created a joint task force to develop the newest guidelines on preventive care for cats and dogs, which came out in September 2011. The members of the Partnership for Preventive Pet Healthcare—the AVMA, AAHA, and other veterinary groups; animal health companies; and other organizations—sponsored the task force and are offering resources to implement the guidelines as part of the new Partners for Healthy Pets program.
“AVMA’s concerns are to make sure we have basic wellness protocols and best practices guidelines for patient care available for the profession,” Dr. Aspros said. “Protocols lead to more consistent and better care.”
Dr. Aspros said his hospitals are very protocol-driven, and they base many protocols on guidelines from established and well-respected veterinary groups. Members of his professional staff study and discuss new guidelines. If they decide to adopt the guidelines, they formulate a new protocol and then educate the entire staff on implementation.
Dr. Mark Russak, AAHA president and a past owner of an animal hospital in Connecticut, said being able to point to guidelines from authoritative veterinary organizations can improve client compliance with veterinarians’ recommendations.
Every year, AAHA task forces develop or revise two to three sets of clinical guidelines on subjects such as nutrition and vaccination.
Dr. Russak noted, “The guidelines and related educational materials are incredibly expensive to develop. We do have sponsors to support these, but they have no input into content.”
AAHA promotes implementation of its guidelines through its website, its member magazine, social media, direct mail, conference sessions, webinars, and other avenues.
When he was in private practice, Dr. Russak turned to AAHA guidelines as credible sources in a sea of opinions.
“As we’re able to do more things for more patients and serve them better, it requires a greater knowledge of what really is the right thing to do and when to do it,” he said.
Dr. Russak also formulated checklists for a variety of situations, including appointments with new patients, to ensure thoroughness and consistency of care. He incorporated the same checklists later in teaching veterinary students at Mississippi State University.
Another adherent of checklists is Dr. Roy Brenton Smith, owner of Central Texas Cat Hospital in Round Rock and president of the American Association of Feline Practitioners.
“There’s a lot of interruptions in what you’re doing in the day, as a veterinarian and as a staff,” Dr. Smith said. He believes checklists are key to reducing omissions and errors, so his hospital has formulated checklists for tasks ranging from receptionists’ duties to the hospitalization of patients.
Dr. Smith said the AAFP offers numerous guidelines to improve feline care. The AAFP Guidelines Committee chooses topics, and task forces develop each document. Sponsors contribute funding to promote implementation of some of the guidelines.
The AAFP’s new Cat Friendly Practice Program helps practices put many of the organization’s guidelines into action, Dr. Smith said. The program certifies practices that meet certain criteria as being cat-friendly.
Dr. Smith said his hospital uses most of what’s in the AAFP guidelines, with some differences in approach.
As a practitioner for 50 years, Dr. Smith has seen a movement toward implementation of clinical guidelines in veterinary medicine.
“We’re trying to encourage people to use them more and more,” he said.