Prognosis and outcome – Using evidence, technology and research to help clients make good decisions

Several years ago, when I was the medical director of my former hospital, I received several complaints from clients about how we discussed prognosis.  In our emergency room and ICU, we sometimes managed patients for multiple days.  Although we tried to schedule ER doctors and criticalists to optimize case continuity, sometimes a client might talk to 3 doctors caring for their pet over 36 hours.  When we were on the same page, this went fine.   Clients however became confused, worried and skeptical if doctors did not seem to be telling the same story.

When we discussed this problem at a doctors meeting, we realized that we often quoted prognosis differently. Sometimes, we discussed what we were taught in school 10 years prior or a paper we had read awhile back. Other times on a busy night, we quoted from memory or what another vet had told us once.

Prognosis – The value of Local Hospital Medical Guidelines

While we had a well-established system of medical care guidelines, we had not included prognosis as part of this.  One of our doctors made the great suggestion for us to survey the literature on common ER diseases and to include prognosis from those papers in our medical guideline sheets.

We divided and assigned 20 common disease syndromes to members of our doctor team and got to work.  While we certainly do not have huge studies or even any studies in some areas, we do have quite a bit of published information that can help.  By listing these studies and prognosis in a readily accessible format, we were able to get our team aligned in what we discussed with clients.

If you would like an example of a medical guideline including prognosis for immune mediated thrombocytopenia, email me at bdavidow@vetidealist.com.

Prognosis – Improvements needed for Electronic Medical Records

However, we also need to figure out ways to use technology to make this information more accessible and usable to doctors during busy emergency room shifts.  We had our medical guidelines on our server so available from every computer but they still had to be opened in a separate program. What if you could enter a diagnostic code as preliminary into your medical record software and it instantly opened a window with your team’s medical guidelines?  Or what if your team could also attach recent journal articles to a diagnostic code for easier access?

Seattle Children’s Hospital has developed medical pathways to help align care to evidence based guidelines.  These pathways are “owned” by a faculty member and updated annually to keep up with changing literature. These pathways are usable for two reasons.  First, these are not nationwide general guidelines – they are locally developed based on the geographic disease risks and antibiograms of this area.  Second, these guidelines are easily accessed directly from the medical record system.

Prognosis – An Example Study

A recent study was published in JAVMA that can be used by veterinarians to talk to clients about prognosis for treatment option in blocked cats.  For many years, most veterinarians have believed that the most effective treatment for male cats with urethral obstruction has been hospitalization with an indwelling urinary catheter hooked to a closed collection system for at least 24 hours.  We have believed that passing a urinary catheter and sending the cat home was likely to lead to re-obstruction.  However, we didn’t really know how often.

In a nicely done prospective study by Seitz, Burkitt-Creedon, and Drobatz, we now know that cats have 3x the risk of re-obstruction by 30 days if they are unblocked and sent home compared to inpatient care with an indwelling catheter.  The study also confirmed that the risk of re-obstruction within 30 days is 10-15%. We also know that pulling the urinary catheter before the urine color has cleared is a risk for re-obstruction.

We need more studies like this that provide comparison of different treatments so that we can discuss risk and benefit of treatment options with owners.

Prognosis – A call for Large Multi-Center Trials

While this urethral obstruction study was of reasonable size, we need much larger numbers of cats to prove a difference if we look at catheter types, different hospitalization lengths, or different anti-spasmotics.

These large-scale studies are difficult and require TIME to collect and analyze the data.  I challenge private equity investors to truly help the profession and by funding needed large scale studies using the caseload in private practice. What types of studies am I referring to? Here are two ER/CC examples:

1) We need prospective studies for IMHA comparing prednisone alone in a set treatment arm versus prednisone and cyclosporine and prednisone versus mycophenolate, but with set anti-coagulant or anti-platelet drug use in each arm. We need a multicenter trial involving large private practices to get enough cases for meaningful conclusions.

To really make studies like this work, there has to be a clinical research coordinator  paid for their time working on the study.  The clinical research coordinator is crucial to make sure everyone enrolls the right patients, follows a set protocol, and collects the correct data. In addition, a study like this needs a statistician involved from the beginning and needs a primary investigator who has enough time and appropriate compensation to write up the results.

2) We need studies on dogs with back pain that are treated with non-steroidal anti-inflammatories (NSAID), treated with steroids, or treated just with pain medication.  These studies should have a sizable number of dogs in each arm and should include at least 6 months of follow up with set home care instructions.  The trial should have a specific NSAID and a specific steroid at set dosages, and set treatment length.  Again, a paid clinical research coordinator and statistician are key to making a study like this work.

Prognosis – Owners need accuracy based on evidence

As discussed in previous blogs  , high quality care is safe, reliable, and effective healthcare that puts pets and their families first. This means our patients and clients need us to help make good treatment decisions by providing evidence-based recommendations.  Because of the dollars involved, clients need us to understand the real cost-benefit analysis of different treatment decisions.  We can serve owners best when we:

1) Develop local hospital guidelines as teams that use evidence to present prognosis

2) Use technology to make these guidelines easily available and useful, and

3) Fund large multi-center studies to provide true prognosis with different treatments