A focus group study of veterinarians' and pet owners' perceptions of the monetary aspects of veterinary care

OBJECTIVE: To compare veterinarians' and pet owners' perceptions of client expectations with respect to the monetary aspects of veterinary care and identify challenges encountered by veterinarians in dealing with pet owners' expectations. DESIGN: Qualitative study based on focus group interviews. PARTICIPANTS: 6 pet owner focus groups (32 owners) and 4 veterinarian focus groups (24 companion animal veterinarians). PROCEDURES: Independent focus group sessions were conducted with standardized open-ended questions and follow-up probes. Content analysis was performed on the focus group discussions. RESULTS: Pet owners expected the care of their animal to take precedence over monetary aspects. They also expected veterinarians to initiate discussions of costs upfront but indicated that such discussions were uncommon. Veterinarians and pet owners differed in the way they related to discussions of veterinary costs. Veterinarians focused on tangibles, such as time and services. Pet owners focused on outcome as it related to their pet's health and well-being. Veterinarians reported that they sometimes felt undervalued for their efforts. A suspicion regarding the motivation behind veterinarians' recommendations surfaced among some participating pet owners. CONCLUSIONS: Results suggested that the monetary aspects of veterinary care pose barriers and challenges for veterinarians and pet owners. By exploring clients' expectations, improving communication, educating clients, and making discussions of cost more common, veterinarians may be able to alleviate some of the monetary challenges involved in veterinarian-client-patient interactions.     

Investigating the opinions of donkey owners and veterinary surgeons towards pain and analgesia in donkeys

The aim of this questionnaire‐based study was to identify which analgesics are currently prescribed to donkeys in clinical practice and to collect opinions from veterinary surgeons and donkey owners on the importance of different pain‐related behaviours in donkeys. Questionnaires were completed by 143 veterinary surgeons and 93 donkey owners. Phenylbutazone, flunixin, detomidine and butorphanol were reported as the most frequently used analgesics in donkeys. Most veterinary surgeons reported administering these drugs at the horse dose rate and dosing interval, which may be inappropriate in the donkey. Four pain‐related behaviours were identified as very important by veterinary surgeons and owners: dullness for colic‐associated pain, keeping the foot lifted, and lameness for foot and limb pain and inability to chew properly for head and dental pain. This is a more limited behavioural repertoire than has recently been identified to be associated with pain in the donkey and suggests that the respondents were reporting perceived wisdom as to what people think are the behavioural signs associated with pain or were not interpreting pain‐related behaviours correctly.     

Conduct,Oversight, and Ethical Considerations of Clinical Trials in Companion Animals with Cancer: Report of a Workshop on Best Practice Recommendations

Development of effective and safe treatments for companion animals with cancer requires the collaboration of numerous animal health professionals and the full engagement of animal owners. Establishing ‘Best Practice Recommendations’ for clinical trials in veterinary oncology represents an important step toward meeting the goal of rigorous clinical trial design and conduct that is required to establish valid evidence. Likewise, optimizing patient welfare and owner education and advocacy is crucial to meet the unique ethical obligations to both owners and animals enrolled in these clinical trials and to ensure trust in the team conducting the research. To date, ‘Best Practice Recommendations’ for clinical trial conduct have not been reported for veterinary oncology. This document summarizes the consensus of a workshop held in November, 2014 to identify relevant ethical principles and to ensure responsible conduct of clinical research in companion animals with cancer. It is intended as a working document that will be updated as advances in science and ethical considerations require. To the extent possible, existing guidelines for the conduct and oversight of clinical trials in humans have been adapted for veterinary trials to avoid duplicative effort and to facilitate integration of clinical trials such that translational research with benefits for both companion animals and humans are encouraged.     

Participatory epidemiology: approaches, methods, experiences

Participatory epidemiology (PE) is an evolving branch of veterinary epidemiology which uses a combination of practitioner communication skills and participatory methods to improve the involvement of animal keepers in the analysis of animal disease problems, and the design, implementation and evaluation of disease control programmes and policies. This review describes the origins of PE and how the application of PE requires attention to both a participatory approach and participatory methods, supported by triangulation of data with conventional veterinary diagnostic methods. The review summarizes the various adaptations and uses of PE, including the design of primary veterinary service delivery systems, veterinary research and disease surveillance. In contrast to conventional data collection methods, an integral aspect PE is the concept of applying and evaluating new disease control programmes or surveillance systems in partnership with animal owners. In the developing regions where PE has been most commonly used, this action-orientated approach raises important challenges for veterinary institutions with limited financial resources. Information derived from PE studies can also question longstanding disease control policies and norms, nationally and internationally.     

Development of a discriminative questionnaire to assess nonphysical aspects of quality of life of dogs

OBJECTIVE: To develop a preliminary discriminative questionnaire for assessment of nonphysical aspects of the quality of life (QOL) of pet dogs and evaluate the questionnaire's content validity, test-retest reliability, and internal consistency. STUDY POPULATION: Owners of 120 dogs. PROCEDURE: Each QOL question had 4 response options, representing descending levels of QOL that were equally weighted. A maximum of 38 items contributed to the QOL score. The questionnaire was administered by telephone to owners of dogs with appointments at a veterinary teaching hospital before the appointment. After the appointment, each dog was classified as sick or healthy by use of defined criteria; owners of healthy dogs had a second interview 3 to 4 weeks later. Test-retest reliability (kappa), internal consistency (Cronbach alpha), and respondents' comprehension were used as criteria for excluding an item. RESULTS: There were 77 sick and 43 healthy dogs. Twenty-two QOL questions had significant kappa values (0.11 to 0.91). The Cronbach alpha values for 5 domains of QOL ranged from 0.45 to 0.61, indicating that the domains had moderate internal consistency (homogeneity). The initial pool of 38 items was reduced to 27. CONCLUSIONS AND CLINICAL RELEVANCE: The questionnaire was designed to complement veterinary assessment of dogs' physical health. The questionnaire may be a useful tool in making decisions regarding dogs' QOL.     

Comparison of owner-reported health problems with veterinary assessment of geriatric horses in the United Kingdom

Reasons for performing study: Previous studies suggest that owners underestimate or incorrectly recognise or report health problems in geriatric horses. However, few studies have directly compared owner‐reported and veterinary assessed disease. Objectives: To compare the findings of veterinary clinical examination of geriatric horses with owner‐reported clinical signs and disease. Methods: A total of 200 horses aged ≥15 years were randomly selected to receive a veterinary examination, from responses to a cross‐sectional postal questionnaire survey. Veterinary examinations were performed within 2 months of questionnaire return, and agreement between owner‐reported data and veterinary clinical findings was assessed. Results: Owners under‐reported many clinical signs and disease conditions detected on veterinary clinical examination. For example, dental abnormalities (detected in 95.4% of horses, reported by 24.5% of owners); cardiac murmurs (detected in 20% of horses, reported by 0.5% of owners); lameness (present in 50% of horses, reported by 23% of owners) and hoof abnormalities (detected in 80% of horses, reported by 27% of owners). Agreement between owner‐reported and veterinary assessed respiratory disease (Kappa 0.02–0.2), body condition score (Kappa 0.24) and coat abnormalities (Kappa 0.42) was poor, fair and moderate, respectively. Range of motion (ROM) of the tarsal and metacarpophalangeal joints was lower in horses with owner‐reported osteoarthritis (P = 0.005 and <0.001, respectively). Conclusions and potential relevance: The low prevalence and relatively poor agreement of owner‐reported disease compared to that detected on veterinary examination suggests inaccurate or under‐recognition, or inaccurate reporting of health problems by owners of geriatric horses, which could lead to a delay in presentation for veterinary treatment. Increased veterinary involvement and improved owner education in the care of geriatric horses should facilitate earlier identification of disease, particularly that which is not readily detectable by owners, and aid management of health and welfare problems.     

A randomised,blinded, crossover study to assess the efficacy of a feed supplement in alleviating the clinical signs of headshaking in 32 horses

Reasons for performing study: Feed supplements are commonly used by owners to alleviate headshaking; however, randomised, controlled trials are required to assess their efficacy. Objective: To determine the efficacy of a feed supplement for alleviation of the clinical signs of headshaking using a randomised, blinded, placebo‐controlled trial. Methods: Using a crossover design, 44 horses previously diagnosed with chronic idiopathic headshaking received both the supplement and a matching placebo per os for 28 days with a washout period between of 14 days. Video recordings were taken at rest and exercise prior to the study and at the end of both periods of treatment. The degree of headshaking was assessed in a blinded, randomised manner by 2 veterinary surgeons. At the same time points, owners completed a questionnaire to assess the severity of headshaking signs. A Wilcoxon signed rank test was used to compare the scores while on supplement and placebo. Results: Using the video assessments, there was no significant difference between scores while on supplement compared with placebo (P = 0.7). Using the questionnaire responses, there was no significant difference between scores for any activity when the placebo and the supplement were compared with each other. However, owners reported significant improvement during all activities for both placebo and supplement compared with pretreatment scores. Conclusions and potential relevance: The supplement offered no benefit over a placebo in alleviating the clinical signs of headshaking. There appeared to be a significant proxy placebo effect when the outcome was based on subjective owner perception of clinical signs. This study demonstrated no beneficial effect of this supplement on the clinical signs of headshaking. The study did show a significant placebo effect, thereby highlighting the necessity of properly conducted, randomised controlled trials, with blinding, to assess true treatment effects in trials in animals.     

Further validation of a pruritus severity scale for use in dogs

A scale to assess the severity of pruritus in dogs was further validated. Comparison of the scale with one containing visible numerical markings demonstrated that owners were heavily influenced by the presence of numbers, resulting in a loss of the scale's ability to generate continuous data. The presence of a traditional visual analogue scale was therefore essential. The scale was tested on 713 owners who presented their dogs for veterinary attention. Pruritus scores in 408 dogs with skin disease covered the full range of possible values (0 to 10). In 305 dogs with no skin disease, 90 owners gave a score greater than zero. Comparison of the scores seen in pruritic dogs, and dogs with no evidence of skin disease, allowed a 'normal range' of 0–1.9 to be established. The scale was able to discriminate between conditions typically regarded as pruritic or non-pruritic. When the scale was assessed for its ability to detect changes in pruritus score following treatment, a median reduction of 4.4 points was observed. The scale was also used to determine what magnitude of response owners would expect following treatment of their pruritic dogs. Only 12% would have been satisfied with a 50% reduction, a figure that is typically quoted as a satisfactory response in clinical trials of anti-pruritic drugs. As a result, alternative methods of assessing clinical trials are proposed. This study has shown the scale to be a valuable tool for clinical assessment of patients, and for monitoring treatment responses in clinical trials.     

Comparison of interpretation of cat's behavioral needs between veterinarians,veterinary nurses,and cat owners

Cats have certain strongly motivated behaviors, which could be defined as “needs,” that should be understood to provide the cat the best quality of life and assure proper welfare. It is well recognized that cats have several behavioral needs, which if not met, can result in anxiety and secondary behavior problems. These problems can lead to relinquishment or euthanasia. Veterinarians and veterinary nurses have a special role when educating owners. To increase owners' compliance, veterinary professionals should have evidence-based knowledge for the right information to be communicated to feline owners. The goal of the present study was to identify and compare the level of knowledge that veterinarians, veterinary nurses, and pet owners have about cat behavior and to compare their perceptions on this subject. We were also interested in determining whether living with a cat affected the professionals' knowledge base and what they are able to properly communicate to pet owners. It was expected that the veterinarians would have the highest level of knowledge regarding the interpretation of feline behavioral needs. We also hypothesized that those professionals who had or have previously owned a cat would have a better understanding of what cats actually need. A questionnaire, called “questionnaire to assess cat's needs” (QACN), was completed by cat owners, veterinarians, and veterinary nurses. The QACN had 13 different statements about the behavioral needs of cats, and each participant had to select their level of agreement with the statement. The QACN was then scored and a principal component analysis was used to identify meaningful associations. The following 3 components were extracted: elimination, stress releasers, and human stimulation. Contrary to what was expected, the results showed that in some specific areas (stress releasers and human stimulation) veterinarians' and veterinary nurses' knowledge was not significantly different from that of cat owners. This could mean that the role of these professionals in preventing behavioral problems can be very compromised. Those professionals who had owned a cat personally were better at identifying the behavioral needs of cats, with some significant differences (related with stress releasers), compared with those professionals who had never owned a cat. More education about feline behavior should be included when training veterinarians and veterinary nurses for clients to continue to trust these professionals to provide them with evidence-based knowledge about cat behavior.     

Comparison of the efficacy of remote consultations and personal consultations for the treatment of dogs which are aggressive towards their owners

Two groups of 42 dogs which were aggressive towards their owners were enrolled into a study designed to compare the efficacy of remote consultations with direct personal consultations for the treatment of the aggressive behaviour. The level of aggression of the dogs was assessed before and after programmes designed to modify their behaviour. Both programmes resulted in a significant reduction in the aggressive behaviour of the dogs towards their owners, and there was no significant difference between the effectiveness of the recommendations, whether they were made without having seen the dog or during a personal consultation with the dog and its owner.     

Evidence‐Based Medicine: The Design and Interpretation of Noninferiority Clinical Trials in Veterinary Medicine

Noninferiority trials are clinical studies designed to demonstrate that an investigational drug is at least as effective as an established treatment within a predetermined margin. They are conducted, in part, because of ethical concerns of administering a placebo to veterinary patients when an established effective treatment exists. The use of noninferiority trial designs has become more common in veterinary medicine with the increasing number of established veterinary therapeutics and the desire to eliminate potential pain or distress in a placebo‐controlled study. Selecting the appropriate active control and an a priori noninferiority margin between the investigational and active control drug are unique and critical design factors for noninferiority studies. Without reliable historical knowledge of the disease response in the absence of treatment and of the response to the selected active control drug, proper design and interpretation of a noninferiority trial is not possible. Despite the appeal of conducting noninferiority trials to eliminate ethical concerns of placebo‐controlled studies, there are real limitations and possible ethical conundrums associated with noninferiority trials. The consequences of incorrect study conclusions because of poor noninferiority trial design need careful attention. Alternative trial designs to typical noninferiority studies exist, but these too have limitations and must also be carefully considered.     

Construction and validation of a risk-screening questionnaire for the investigation of recurrent airway obstruction in epidemiological studies of horse populations in Great Britain

Recurrent airway obstruction (RAO) is an environmental respiratory disease affecting horses. A risk-screening questionnaire (RSQ) for RAO would provide a useful tool to investigate the epidemiology of the disease in horses; our aim in this study was to construct and validate such an instrument. Guidance for what questions to include in the RSQ came from three processes: a review of the scientific literature, a survey of equine practitioners in the UK and a consultation with 19 experts using a modified Delphi technique. The latter consultation consisted of two rounds; agreement amongst the experts increased between the rounds. The quantitative outputs provided estimates of the probabilities of a horse having RAO for each particular piece of historical information or clinical sign. The RSQ for RAO was a short questionnaire for completion by horse owners regarding the horse, its health and its management. The likelihood of a horse having RAO (the RAO score) was calculated from a completed RSQ by combining the relevant estimated probabilities. The RSQ was validated against a reference standard of a veterinary diagnosis including respiratory cytology. This was achieved by inviting veterinary surgeons (residing in Great Britain who had taken part in the practitioner survey, and who had indicated that they used respiratory cytology in the diagnosis of respiratory cases) to participate. During 2003 and 2004 these veterinary surgeons returned RSQs for 40 cases that underwent investigation of the respiratory tract and 40 controls; 18 of the cases were given a final diagnosis of RAO. A receiver-operating characteristic (ROC) curve was used to select a positive cut-off of 0.87 for the RSQ for RAO. This suggested that the RSQ had a sensitivity of 0.83 (95% confidence interval=0.59-0.96) and specificity of 0.85 (0.74-0.93) for the diagnosis of apparent RAO (compared to all other diagnoses).     

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     

Clinical Evaluation of Methods of Treatment

Veterinary clinicians can make a significant contribution to the knowledge of the practical value of using alternative treatment methods by conducting clinical trials. By following a logical sequence of steps the clinician can design and participate in a clinical trial in his clinic without interfering with his normal practice. The successive stages of a field trial were presented along with an example to demonstrate the application of the principles involved. These stages are: design and planning, implementation, collection of data, and analysis of data.

The veterinary clinician who initiates clinical trials to answer questions plaguing him provides two services to the veterinary profession. First, he helps answer questions facing private practitioners throughout the profession. Second, he can demonstrate that not all research must be done in a laboratory setting isolated from “real world” complications. Seeing the results that can be derived from individual practicing veterinarians participating in clinical trials should act as a stimulus to other veterinarians to logically organize the data coming from their practices.

     

Euthanasia & thanatology in small animals

The study of thanatology has recently taken on increased importance in the field of veterinary medicine. Today, the roles of companion animals have expanded to include beloved pet and family member, provider of social and emotion support, and in the case of service dogs, provider of assistance to owners with special needs. For these reasons, companion animals have taken on greater significance within their human families. Their deaths can be as painful and difficult for their families as the death of human family members. Veterinarians are tasked with working in concert with the pet owner, throughout the lifetime of the pet, to promote the pet’s health and well-being. In critical and or terminal situations, it is the veterinarian’s role to educate the owner so that informed decisions regarding treatment options or a decision to euthanize the pet can take place. In veterinary medicine, euthanasia means to end life painlessly. Veterinarians and owners, working in partnership to make subjective and objective assessments on the pets quality of life, produce the best results. For the veterinarian, the medical approach (including: clinical history, physical exam, laboratory tests, diagnosis, prognosis and treatment) can assist in assessing the pet’s physical health status, any potential treatments, and the likely short and long term outcomes. The owner’s role in the partnership is to subjectively assess overall behavioral changes and the pet’s quality of life. Once owners have decided to euthanize their pet, there are still more factors to consider: where to perform the procedure, which family members will be present, and how the remains will be handled. The veterinarian can do everything possible to minimize any anxiety for the pet during the euthanasia, including administration of a tranquilizer prior to the procedure. The veterinarian will allow the pet’s family time to say goodbye and educate them on what to expect when their pet dies. There is a possibility that other pets that lived in the same household may also experience distress at the loss of their animal family member. The veterinarian can let the owners know what signs may be signaling depression or anxiety in that pet. The grieving process is extremely personal and people must be allowed to grieve in the way that helps them deal with their loss. Veterinarians need to be careful not to minimize the owner’s loss or grief. The owner will count on the veterinarian’s guidance and expertise when making decisions affecting their pet’s well-being. Making an informed decision can help assuage any guilt about opting for euthanasia when done in the best interest of the pet.     

Can owners assess outcome following treatment of canine cruciate ligament deficiency?

Forty-seven owners of 48 dogs surgically treated for cranial cruciate ligament deficiency were asked to assess the outcome of treatment at one year postsurgery. A standard visual analogue scale assessment tool was used in all cases and owners were asked to score a variety of generic and disease-specific features. The reliability and responsiveness of the assessment tool were estimated and found to be acceptable; generic features, such as 'level of disability', showed the greatest reliability and responsiveness. The results of assessments by owners were compared to assessments by a veterinary surgeon but few significant correlations were found. Assessments by owners appear to be a useful outcome measure in this disease but are unlikely to be directly comparable to assessments by a veterinary surgeon.     

Psychiatric investigation of 18 bereaved pet owners

This survey explores the grief associated with the loss of a pet, and was carried out using a self-administered questionnaire. The questionnaires were handed out to 50 bereaved pet owners attending a public animal cremation service, and we received 18 responses. Participants responded within 0 to 44 (median 4) days of the death of their pet. Although most mental health problems immediately following mourning are presumed to be normal grief reactions, on the basis of several psychiatric scales, 8 of the 16 valid responses indicated depression and/or neurosis. Statistical analyses showed that the following factors were significantly associated with grief reactions: age of owner, other stressful life events, family size, age of deceased animal, rearing place, and preliminary veterinary consultation.