Is evidence-based medicine so evident in veterinary research and practice? History,obstacles and perspectives

Evidence-based medicine (EBM) refers to the conscientious, explicit and judicious use of current best evidence from research for the care of an individual patient. The concept of EBM was first described in human medicine in the early 1990s and was introduced to veterinary medicine 10 years later. However, it is not clear that the EBM approach promulgated in human medicine can be applied to the same extent to veterinary medicine. EBM has the potential to help veterinarians to make more informed decisions, but obstacles to the implementation of EBM include a lack of high quality patient-centred research, the need for basic understanding of clinical epidemiology by veterinarians, the absence of adequate searching techniques and accessibility to scientific data bases and the inadequacy of EBM tools that can be applied to the busy daily practise of veterinarians. This review describes the development of EBM in the veterinary profession, identifies its advantages and disadvantages and discusses whether and how veterinary surgeons should further adopt the EBM approach of human medicine.     

Evidence based medicine in veterinary daily practice

The veterinary practitioner should base decisions concerning diagnostic procedures and treatments in practice on recent, valid and clinically relevant information. He may rely on journal papers, colleagues, the internet or other sources. It is a great challenge to find appropriate information in a reasonable time. Furthermore, the practitioner has to judge the information regarding its actuality and validity. Ideally, such information should provide a high level of evidence. This means that this information is more likely to be "correct". Good information can be obtained through high quality trials, such as randomized and blinded controlled clinical trials. Universities, publishers and professional organizations should promote editing of scientific information to support practitioners in decision making.     

Use of cytology as a diagnostic method in veterinary practice and assessment of communication between veterinary practitioners and veterinary clinical pathologists

OBJECTIVE: To determine the extent of use of cytology as a diagnostic method in veterinary practice and assess how veterinarians in practice communicate with veterinary clinical pathologists. DESIGN: Online survey. STUDY POPULATION: 870 veterinarians. PROCEDURES: An online survey was made available to members of the Veterinary Information Network from October 1, 2004, through December 1, 2004. RESULTS: Respondents reported obtaining a median of 7 cytology samples weekly (range, 0 to 100). On average, respondents reported that 48.1% of the samples they collected were evaluated in-house, 29.5% were submitted to a veterinary diagnostic laboratory, and 21.6% were evaluated in-house and then submitted to a diagnostic laboratory. Most respondents (89.2%) reported using cytologic assessments to guide additional testing, and most (80.3%) indicated that they found the comments section of the cytology report to be the most important section. When asked to indicate the importance of various factors in their decision to use cytology as a diagnostic method, respondents overwhelmingly indicated that accuracy was very important. The most common reasons for consulting with a clinical pathologist were to discuss a discrepancy between clinical and cytologic findings, to clarify a diagnosis, and to ascertain the pathologist's confidence in a diagnosis. Respondents expressed more confidence in results when board-certified clinical pathologists were examining cytology samples than when others were. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that improving communication between veterinary practitioners and veterinary clinical pathologists could enhance the diagnostic value of cytologic examinations and improve clinical decision-making.     

Computerised decision support in veterinary medicine,exemplified in a canine idiopathic epilepsy care pathway

Computerised decision support is of emerging and increasing importance in human medicine, but as yet has not been thoroughly applied or evaluated in veterinary medicine. In this essay, the authors report on the first example of a veterinary care pathway, a specific form of computerised decision support, which guides clinicians through a clinical workflow and incorporates individual patient data to inform patient-specific decision recommendations. The veterinary care pathway was designed using consensus statements and specialist neurologist opinion to create a decision support tool concerning canine idiopathic epilepsy. The authors evaluated the care pathway by comparing 35 clinical decisions made by referral clinicians in historical cases of idiopathic epilepsy to decisions recommended by the care pathway when presented with the same clinical case. Their results show that in 77.1% (95% confidence interval [59.9, 89.6]) of cases the care pathway recommended a decision that was the same or similar to a specialist neurologist's decision. Whilst further studies are needed to explore the potential use of such technology in clinical practice, the authors believe this first application provides great promise of a new and alternative method of clinical decision support.     

Assessment of quality of life in equine patients

Reasons for performing study: Assessing patients' quality of life (QOL) is a core part of clinical decision making. Various methodologies for assessing patients' QOL have been developed in human medicine and small animal veterinary disciplines. In contrast, the lack of aids for QOL assessment in equine veterinary practice leaves practitioners reliant on subjective assessments of QOL, which may be prone to avoidable errors. Objectives: This paper suggests pragmatic ways in which QOL may be enhanced, while remaining appropriate for the time, financial and owner‐based constraints within equine practice. Methods: Through interdisciplinary research, this paper identifies, adapts and applies insights from several areas of research and practical experience in order to develop an overarching approach to making QOL‐based decisions in clinical cases. Results: The paper identifies 6 steps involved in QOL‐based decision making and provides examples of how these steps may be practically applied. These include deciding what each clinician feels is important; deciding how to evaluate it, including taking owners' views into consideration; making decisions about each case and achieving the desired clinical outcomes. Conclusions: Practitioners can draw their own conclusions on how they may improve QOL assessment in practice and may usefully share these with colleagues. Reporting cases and sharing practical examples of QOL tools used on the ground are vital to the development of this field and appropriate methodologies. Potential relevance: Improvements in QOL assessment are relevant to all areas of equine veterinary practice, and several areas of research. Further research may develop QOL assessment in practice, but more important are the personal improvements that each practitioner may achieve. See also correspondence by Grove     

Searching for veterinary evidence: A guide for equine professionals

There is more and more online information available at our fingertips, but how do we efficiently identify and extract relevant information for good clinical decision making? The aim of this review article is to provide equine professionals with the building blocks to be able to develop skills for expertly navigating the scientific literature in a timely fashion. This includes what key questions you need to ask before starting (why am I searching and how much time do I have), where the best places are to search and how to find freely available legal copies of papers (articles, conference proceedings, book chapters and dissertations). Additionally, how to best conduct an information search and what you get from searches of varying comprehensiveness. Finally, this article will cover where to find databases of research syntheses where others have already carried out the hard work for you and some advanced techniques which are likely to save you substantial amounts of time. This article draws together expertise from a panel of veterinary clinicians, nurses and technicians, information specialists and librarians and clinical researchers.     

Evidence based veterinary medicine

The characteristics and advantages of evidence based (human-) medicine (EBM) are introduced. By summarising information and analysing the results of different clinical trials relating to a specific topic by expert commissions concise and advanced conclusions can be formulated. That kind of evidence (certainty that results are true) increases the explanatory power of a single trial by far. Precondition for the development of an evidence based veterinary medicine (EBVM) is an improvement of the quality, design and implementation of clinical trials. Continuous publication of these conclusions (EBVM) can support the practitioner or clinician in the decision making process for an optimal treatment. Furthermore the implementation of state of the art intervention strategy is assured.     

Rural veterinary services in Western Australia: Part A. Government veterinary services

OBJECTIVE: To determine the status of rural veterinary services in Western Australia. PROCEDURE: Two questionnaires were mailed to eligible, registered veterinary surgeons in Western Australia in 2006. The first was mailed to government veterinarians and the second to private practitioners in rural practice. Part A presents the replies from government veterinary officers and Part B the replies from rural practitioners. Replies were transferred to Microsoft Excel for analysis. RESULTS: Sixty-seven per cent of government veterinary officers responded to the questionnaire. Eighty per cent of these had been in the service for 20 years or more and their average age was 54. Work with sheep and beef cattle occupied 75% of their time, with dairy cattle receiving 10% and pigs and poultry less than 10%. The majority of respondents reported changes in the attitude of farmers to the service as a result of rural recessions and the decision to make a direct charge for government veterinary services. Although most respondents thought that the government veterinary service would continue in the future there were differences of opinion as to what form that would take. CONCLUSION: Government veterinary services in Western Australia are undergoing major changes, with the service decreasing in size and scope. Recently the Department of Agriculture has been renamed the Department of Agriculture and Food and it is likely that the role of its veterinary officers will change accordingly.     

Evidence-based veterinary medicine: what it is, what it isn't and how to do it

EBM represents a more formal process for considering the merits of published research in the context of clinical decision making. By combining the application of formal rules of evidence in evaluating the clinical literature (critical appraisal) with the ability to conduct efficient and effective literature searches, any clinician is able to keep current on topics of interest. Learning the core skills that enable the practice of EBM is easier than expected. The EBM Working Group published a series of Users' Guides to enable clinicians to learn critical appraisal of the primary literature in a systematic fashion. The complete series of Users' Guides is available free of charge over the web (www. CCHE.net). Similarly, PubMed, which contains a number of easy to use search filters (Clinical Queries) that can identify high-quality papers published in key veterinary journals, is also available free of charge over the web (www.PubMed.org). How ever one obtains the core skills, an efficient, structured approach to the practice of EBM can actually reduce the amount of time one requires to keep current by helping the user locate and identify methodologically rigorous research. Although the entire process can be self-taught, as with any new technique, other effective ways to bring these new skills into your practice setting include attending a conference workshop or even hiring a new graduate who has already been trained in the process.     

Veterinary opinions on refusing euthanasia: justifications and philosophical frameworks

To obtain information on euthanasia decisions from practising veterinary surgeons, respondents were asked to estimate how often during their time in practice they had refused to euthanase a dog and how often they had wanted to refuse to euthanase a dog but not done so because of other pressures. For each, respondents were then asked to state their most common reasons for refusing/not refusing in free text. The responses of clinicians were considered in the light of established ethical concepts to produce an evidence-based ethical framework for decision making. In total, 58 practitioners responded. Common reasons given for decisions on whether to refuse euthanasia referred to the patient's interests, such as the possibility of treatment or rehoming, and the fear of other unacceptable outcomes for the dog. Other reasons were based on concern for owners' interests. Some respondents reported being pressured into euthanasia by clients and other veterinary surgeons. This gives insight into the ethical principles that explicitly underlie veterinary surgeons' euthanasia decisions and the resultant framework may be useful for discussing and teaching euthanasia.     

Information-seeking behaviors of first-semester veterinary students: a preliminary report

Although emphasis in veterinary education is increasingly being placed on the ability to find, use, and communicate information, studies on the information behaviors of veterinary students or professionals are few. Improved knowledge in this area will provide valuable information for course and curriculum planning and the design of information resources. This article describes a survey of the information-seeking behaviors of first-semester veterinary students at Purdue University. A survey was administered as the first phase of a progressive semester-long assignment for a first semester DVM course in systemic mammalian physiology. The survey probed for understanding of the scientific literature and its use for course assignments and continuing learning. The survey results showed that students beginning the program tended to use Google for coursework, although some also used the resources found through the Purdue libraries' Web sites. On entering veterinary school, they became aware of specific information resources in veterinary medicine. They used a small number of accepted criteria to evaluate the Web site quality. This study confirms the findings of studies of information-seeking behaviors of undergraduate students. Further studies are needed to examine whether those behaviors change as students learn about specialized veterinary resources that are designed to address clinical needs as they progress through their training.     

Food systems veterinary medicine

The objectives of this review are to suggest the use of the systems thinking framework to improve how veterinary medicine is applied to food production. It applies the eight essential skills of systems thinking to a few selected veterinary examples. Two of the skills determine how we approach or define a problem, and are (i) dynamic thinking (taking a longer term perspective) and (ii) the 30,000 foot view (expanding the boundary of analysis beyond the animal, farm, or even country). The other skills are (iii) system-as-cause, (iv) operational thinking, (v) closed-loop (feedback) thinking, (vi) non-linear thinking, (vii) scientific thinking and (viii) generic thinking. The challenge is to adopt and apply this systems framework to veterinary medicine and food production. The result will be a rigorous new approach to solving the complex food and health problems of the 21st century.     

Nonspecific clinical signs in pigs and use of exclusion diagnosis for classical swine fever: a survey among pig farmers and veterinary practitioners

Outbreaks of Classical Swine Fever (CSF) occurred in spring 2006 in Germany close to the Dutch border. On 6th April Dutch pig farmers were given the possibility to submit blood samples directly via their veterinary practitioner to the National Reference Laboratory for CSF if their pigs had non-specific clinical symptoms or if pigs were being treated with antibiotics. The pig farm was not quarantined and was not visited by the veterinary authorities. Over a period of 9 weeks 156 pig farmers submitted whole blood samples via 50 different veterinary practices. All samples tested negative in the PCR test. These pig farmers and veterinary practitioners were asked to respond to a postal questionnaire with questions regarding their experience with this new diagnostic possibility, the distribution of the costs involved, a comparison with other instruments, such as official notification or use of a leukocyte count test, and their knowledge of clinical signs of CSF. 65 pig farmers (42%) and 33 veterinary practices (66%) returned the questionnaire. The main results indicated that pig farmers (72%) would use this type of exclusion diagnostics sooner than that they would approach the veterinary authorities (practitioners: 86%). Moreover the respondents considered the fact that the farm was not quarantined immediately to be an advantage (pig farmers, 79%; practitioners, 88%). 32 percent of the pig farmers were not aware that they were required to submit blood samples if pigs were being treated with antibiotics (practitioners: 11%). The majority of pig farmers and practitioners were not satisfied with the current distribution of the costs involved: in their opinion the costs of the PCR test, the costs of the veterinary practitioner and the costs for shipping the samples to the reference laboratory should be paid out of the Animal Health Fund (50% government and 50% industry) or by the government. If the current distribution of the costs is not changed, a large proportion of the pig farmers indicated that they would not use this form of exclusion diagnostics for CSF in the future. Pig farmers appeared to have a rather limited knowledge of the clinical signs of CSF: 33% of the pig farmers could mention maximally three clinical signs of CSF, and 7% could not mention a single clinical sign of CSF and said they were entirely dependent on the practitioners' ability to judge a CSF-suspect situation.     

Training evidence-based veterinary medicine by collaborative development of critically appraised topics

In current veterinary education, skills such as retrieving, critically appraising, interpreting, and applying the results of published scientific studies are rarely taught. In this study, the authors tested the concept of team-based development of critically appraised topics (CATs) in training students in evidence-based veterinary medicine (EBVM). The 116 participants were in their fifth year and attending the clinical rotation at the Clinic for Animal Reproduction. Students developed 18 CATs of varying quality on topics of their choice. Preparing the CATs in teams stimulated discussion on the topic and the quality of the retrieved papers. Evaluation of the project revealed that more than 90% of the students endorsed training in critical appraisal of information in veterinary education. In addition, more than 90% considered the development of CATs an effective exercise for assessing the quality of scientific literature. A provided literature evaluation form was perceived as a useful tool for systematically summarizing a publication's quality. In conclusion, team-based development of CATs during clinical rotations is highly valuable for training in EBVM. Learning and intrinsic motivation seem to be enhanced by creating a situation similar to veterinary practice because the task is embedded into an authentic clinical problem. This approach to clinical training helps to prepare students to integrate evidence from literature into practice.     

Teaching veterinary students beef production medicine with student/producer teams

Veterinary colleges face difficulties in meeting the demand for rural veterinarians with the scope to practice quality production medicine. Increasing population density around veterinary colleges, retaining the interest of students with a background in animal agriculture, and educating students without a farm background requires that veterinary colleges consider innovative ways to not only teach traditional food-animal practice but give future veterinarians the advanced skills the food industry demands. This article describes a three-year elective program, Beef Records Analysis, in which beef production medicine is taught by teaming a student and a beef producer together early in the student's veterinary education. These producer/student teams complete risk assessments, balance rations, collect financial and production information, and evaluate back-grounding and feedlot enterprises. Students learn how to evaluate their producers using industry benchmarks and past performance records and how to communicate their findings back to their producer. Producers often make management decisions based on the students' findings, and, because the students maintain their relationships with producers for three years, they can assess the outcomes of the producers who follow or ignore their recommendations and interventions. Students share recommendations and outcomes associated with their herd with the entire class. This allows students to learn how to establish best management practices through objective analysis of outcomes of recommended practices of all herds represented in the class. While a formal assessment of the course is needed, the students rate the program very high on evaluations.     

Connecting knowledge resources to the veterinary electronic health record: opportunities for learning at point of care

Electronic health records (EHRs) provide clinical learning opportunities through quick and contextual linkage of patient signalment, symptom, and diagnosis data with knowledge resources covering tests, drugs, conditions, procedures, and client instructions. This paper introduces the EHR standards for linkage and the partners-practitioners, content publishers, and software developers-necessary to leverage this possibility in veterinary medicine. The efforts of the American Animal Hospital Association (AAHA) Electronic Health Records Task Force to partner with veterinary practice management systems to improve the use of controlled vocabulary is a first step in the development of standards for sharing knowledge at the point of care. The Veterinary Medical Libraries Section (VMLS) of the Medical Library Association's Task Force on Connecting the Veterinary Health Record to Information Resources compiled a list of resources of potential use at point of care. Resource details were drawn from product Web sites and organized by a metric used to evaluate medical point-of-care resources. Additional information was gathered from questions sent by e-mail and follow-up interviews with two practitioners, a hospital network, two software developers, and three publishers. Veterinarians with electronic records use a variety of information resources that are not linked to their software. Systems lack the infrastructure to use the Infobutton standard that has been gaining popularity in human EHRs. While some veterinary knowledge resources are digital, publisher sites and responses do not indicate a Web-based linkage of veterinary resources with EHRs. In order to facilitate lifelong learning and evidence-based practice, veterinarians and educators of future practitioners must demonstrate to veterinary practice software developers and publishers a clinically-based need to connect knowledge resources to veterinary EHRs.     

Evidence-based veterinary medicine: evolution, revolution, or repackaging of veterinary practice?

Over time, evidence-based veterinary medicine (EBVM) should integrate with normal clinical practice. Also, clinical knowledge increases with EBVM, reducing the need for information in one area and allowing veterinarians to explore new areas of specialty or cutting-edge advances in the profession. Textbooks, journals, veterinary conferences, and web sites provide nearly unlimited information about EBVM for the practicing veterinarian to help with the transition to EBVM use in daily practice life. EBVM should continue to change and improve how we, as veterinarians, provide the best available care to our clients and patients.     

Maximising canine welfare in veterinary practice and research: a review

This article looks at the existing evidence-base by which veterinary surgeons can make welfare-focused treatment choices. Narrative and structured reviews were conducted. Papers were categorised under headings based on (1) themes in the UK Animal Welfare Act (AWA 2006) - behaviour, environment, nutrition, company and health; (2) iatrogenic harm induced by treatment; (3) decision-making methods, and (4) the subjects' context (e.g. home versus laboratory). There is more information available about 'overt' problems (e.g. acute disease), than 'covert' issues (e.g. chronic pain, lack of company and obesity). Forty of 109 papers covered pain, suffering, injury and disease, compared to 69 across four other themes in the AWA. Twelve papers were identified as focusing on welfare assessment and clinical decision-making. Veterinary surgeons should consider each of the five welfare themes described in the AWA in both veterinary practice and in determining veterinary research priorities.     

Evidence-based medicine concepts.

Today, the busy clinician benefits from a philosophy of practice that brings together the best applicable evidence and the experiences of clinical work in an effort to provide the best care for individual patients. EBM provides a structured approach that recognizes the contributions of evidence and clinical experience. An EBM practice is efficient and effective in meeting the goal of assuring optimum care. The concepts of EBM make sense for veterinary medicine (even if there are limited numbers of randomized, blinded studies), and clinicians in all types of practice can apply them.