What outcomes should be measured in feline chronic kidney disease treatment trials? Establishing a core outcome set for research.

Chronic Kidney Disease (CKD) is an important cause of feline morbidity and mortality. There is currently no agreement on which outcomes are most important in CKD treatment trials to assist evidence-based decision making. Core Outcome Sets (COSs) originated in human healthcare and are an agreed set of outcomes to be measured and reported as a minimum in any trial conducted relating to a particular disease. To establish a COS for feline CKD, this study used a systematic review and two consensus methodologies (an electronic Delphi (eDelphi), and an in-person consensus meeting), with an international panel of key stakeholders. The systematic review identified 104 unique published parameters, which were rated by panellists in round 1 of the eDelphi. Panellists were also asked to suggest additional parameters. In round 2 these additional parameters were rated and any parameters not understood by >10 % of panellists in round 1 were redefined and re-rated. Parameters reaching consensus in rounds 1 and 2 were removed from round 3, when all remaining parameters were re-rated by panellists who could view their own previous rating alongside the median rating of the whole panel. To reach inclusion in the COS, parameters had to be rated 8 or 9 on a Likert scale of 1-9 (where 1 was not important and 9 was very important) by more than 80 % of panellists. In the consensus meeting, panellists discussed and re-rated borderline parameters and streamlined the final COS. Borderline parameters were those that had been closest to, but not achieved, the 80 % threshold for inclusion. The eDelphi panel (n = 73) rated 24/104 parameters highly enough for inclusion and proposed an additional 20 parameters, of which 3 reached the inclusion threshold. This totalled 27 parameters for inclusion. The consensus meeting panel (n = 16) rated an additional 6/20 borderline parameters highly enough for inclusion. During the streamlining process, 4 parameters were removed as one was considered not an outcome, and three were already addressed by other parameters. The remaining COS totalled 29 parameters. These were grouped into 9 core themes: clinical examination, quality of life, serum biochemistry, complete blood count, urinalysis, total amount of food eaten, CKD progression, survival time and cause of death. This is the first COS for feline medicine. In future treatment efficacy trials the COS will strengthen the evidence-base for this condition, by facilitating easier comparison of results between studies, and reduce research waste.

A systematic review of the quality of life assessment tools for cats in the published literature.

Quality of life (QoL) is an important parameter to assess in cats, as it can be pivotal to important decision-making. Research reports that owners of cats with heart disease would trade longevity for QoL, and treatment associated improvement in QoL is very important for cats with chronic kidney disease. This systematic review aimed to explore the published literature to identify the number and range of QoL assessment tools available to researchers and veterinary professionals, by discovering tools which have already been used in published studies. Medline and CAB Abstracts were searched in March 2018, using terms relevant to cats and QoL or well-being. Inclusion and exclusion criteria were applied and information on uniqueness, validation and a short description of each tool extracted. A total of 1138 manuscripts were identified, of which 96 met all criteria. Forty of 96 manuscripts contained an assessment of QoL, using one of 32 unique tools identified. Sixteen of the tools identified were structured, making detailed patient assessments. Only eight of the structured tools were validated, and of these, three could be applied to healthy cats; the remainder being specific to a disease or being hospitalised. Some validated tools appeared in more than one manuscript. Overall, 12 manuscripts used a validated tool. In the 16 unstructured tools, five tools assessed QoL by assigning a single word (e.g. 'poor'). Eight tools assessed QoL on a single Likert scale (e.g. a number between 1 and 5). This work identifies the tools that are currently available for the assessment of QoL by researchers and veterinary professionals. Additionally, it demonstrates that many are not validated or lack detailed animal assessment, highlighting that further work in this important area is needed.

Measuring the success of canine and feline preventative healthcare consultations: A systematic review.

Preventative healthcare consultations account for a large proportion of the veterinary caseload. This novel study is the first to methodically review all literature on canine and feline preventative healthcare consultations. Previous research has found these consultations to be different from health problem consultations in terms of communication style and content. Identifying relevant evidence and previously validated methods of measuring the success of these consultations will be useful when implementing strategies for optimisation. The aim of this study was to identify and assess the quality of existing literature which describes and/or measures the success of preventative healthcare consultations. Database searches of CAB Abstracts and Medline were conducted to identify published literature. Google searches were then conducted to identify any additional published or grey literature. Results were systematically screened to determine whether the returned sources were about cats and/or dogs, whether they related to preventative healthcare, and whether they described and/or measured the success of preventative healthcare consultations. For primary research citations which only described preventative healthcare consultations, data were extracted on the aspects of the consultations described. For citations which additionally measured the success of the consultations, the measures used, sampling technique, key results and key weaknesses were also extracted. Of 17,538 citations identified in total during the database searches, a total of seven relevant primary research citations were identified. All of these citations described aspects of the preventative healthcare consultation, such as consultation length, health problems discussed, actions taken and communication style. Only one primary research citation measured success of the consultation, using veterinarian satisfaction to determine success. In addition, 30 narrative citations, including expert opinion pieces, textbooks, guidelines without transparent methodology and conference presentations were identified. Google searches identified 224 relevant narrative citations, and five of the seven primary research citations identified by the database searches, but did not identify any additional relevant primary research citations. The results suggest that, despite accounting for around a third of all consultations, there is relatively little evidence describing preventative healthcare consultations and only one measure of success has been described for these consultations. This presents potential challenges when implementing strategies to optimise these consultations, as measures which are useful and relevant to veterinary practice should first be identified. Identifying useful measures of success will allow future strategies designed to maximise the benefits of these consultations to be meaningfully assessed for efficacy.

Sample size and number of outcome measures of veterinary randomised controlled trials of pharmaceutical interventions funded by different sources, a cross-sectional study.

BACKGROUND: Randomised controlled trials (RCTs) are a key component of the veterinary evidence base. Sample sizes and defined outcome measures are crucial components of RCTs. To describe the sample size and number of outcome measures of veterinary RCTs either funded by the pharmaceutical industry or not, published in 2011. METHODS: A structured search of PubMed identified RCTs examining the efficacy of pharmaceutical interventions. Number of outcome measures, number of animals enrolled per trial, whether a primary outcome was identified, and the presence of a sample size calculation were extracted from the RCTs. The source of funding was identified for each trial and groups compared on the above parameters. RESULTS: Literature searches returned 972 papers; 86 papers comprising 126 individual trials were analysed. The median number of outcomes per trial was 5.0; there were no significant differences across funding groups (p = 0.133). The median number of animals enrolled per trial was 30.0; this was similar across funding groups (p = 0.302). A primary outcome was identified in 40.5% of trials and was significantly more likely to be stated in trials funded by a pharmaceutical company. A very low percentage of trials reported a sample size calculation (14.3%). CONCLUSIONS: Failure to report primary outcomes, justify sample sizes and the reporting of multiple outcome measures was a common feature in all of the clinical trials examined in this study. It is possible some of these factors may be affected by the source of funding of the studies, but the influence of funding needs to be explored with a larger number of trials. Some veterinary RCTs provide a weak evidence base and targeted strategies are required to improve the quality of veterinary RCTs to ensure there is reliable evidence on which to base clinical decisions.

Sponsorship bias and quality of randomised controlled trials in veterinary medicine.

BACKGROUND: Randomised controlled trials (RCTs) are considered the gold standard form of evidence for assessing treatment efficacy, but many factors can influence their reliability including methodological quality, reporting quality and funding source. The aim of this study was to examine the relationship between funding source and positive outcome reporting in veterinary RCTs published in 2011 and to assess the risk of bias in the RCTs identified. METHODS: A structured search of PubMed was used to identify feline, canine, equine, bovine and ovine clinical trials examining the efficacy of pharmaceutical interventions published in 2011. Funding source and outcomes were extracted from each RCT and an assessment of risk of bias made using the Cochrane risk of bias tool. RESULTS: Literature searches returned 972 papers, with 86 papers (comprising 126 individual RCTs) included in the analysis. There was found to be a significantly higher proportion of positive outcomes reported in the pharmaceutical funding group (P) compared to the non-pharmaceutical (NP) and 'no funding source stated' (NF) groups (P = 56.9%, NP = 34.9%, NF = 29.1%, p < 0.05). A high proportion of trials had an unclear risk of bias across the five criteria examined. CONCLUSIONS: We found evidence that veterinary RCTs were more likely to report positive outcomes if they have pharmaceutical industry funding or involvement. Consistently poor reporting of trials, including non-identification of funding source, was found which hinders the use of the available evidence.

Common decisions made and actions taken during small-animal consultations at eight first-opinion practices in the United Kingdom.

In order for veterinary surgeons to undertake an evidence-based approach to making decisions about their patients, it is important that new evidence is generated to support the clinical decision-making process. Many of the decisions are likely to be around the actions taken to treat or manage health problems discussed during the consultation, and little is currently known about the factors which affect the type of action taken. The aim of this study was to determine the decisions made and actions taken for health problems discussed during first-opinion small-animal consultations, as well as identifying factors which may affect the decision-making process. Data were gathered during direct observation of small-animal consultations conducted by 62 veterinary surgeons in eight first-opinion practices in the United Kingdom. For each patient presented, data were gathered on all health problems discussed during the consultation. The decision made (whether an action was taken or not) and the action taken where applicable (e.g. therapeutic treatment with antibiotics) was also recorded. A three-level multivariable logistic-regression model was developed, with problem (Level 1) nested within patient (Level 2) nested within consulting veterinary surgeon (Level 3), and a binary outcome variable of action versus no action. At least one action was taken for 69% (n=2203/3192) of all problems discussed. Therapeutic treatment was the most common action taken (n=1286/3192 problems; 40.3%), followed by management advice (n=1040/3192; 32.6%) and diagnostic work-up (n=323/3192; 10.1%). The most common therapeutic treatment was antibiotics (n=386/1286; 30%), while the most common management advice given was dietary advice (n=509/1040; 48.9%). The three explanatory variables remaining in the final model were whether the problem was a presenting or non-presenting problem, the type of diagnosis made, and the body system affected. Explanatory variables which did not remain in the final model were patient signalment, problem history, consultation type, clinical examination type, and who raised the problem (veterinary surgeon or owner). For over two-thirds of problems discussed, an action was taken which suggests these problems may be seen as important by the veterinary surgeon and/or pet owner. No action was taken for almost a third of cases which could represent 'watchful waiting', which has been highlighted as important in human healthcare. Future research should focus on the common actions taken, further exploring the complex decision-making process, and examining the effect of the decisions made on long-term patient outcomes.

Evaluating veterinary practitioner perceptions of communication skills and training.

A survey was conducted among veterinary practitioners in the UK and the USA in 2012/2013. Thematic analysis was used to identify underlying reasons behind answers to questions about the importance of communication skills and the desire to participate in postgraduate communication skills training. Lack of training among more experienced veterinary surgeons, incomplete preparation of younger practitioners and differences in ability to communicate all contribute to gaps in communication competency. Barriers to participating in further communication training include time, cost and doubts in the ability of training to provide value. To help enhance communication ability, communication skills should be assessed in veterinary school applicants, and communication skills training should be more thoroughly integrated into veterinary curricula. Continuing education/professional development in communication should be part of all postgraduate education and should be targeted to learning style preferences and communication needs and challenges through an entire career in practice.

Factors influencing common diagnoses made during first-opinion small-animal consultations in the United Kingdom.

It is currently unclear how frequently a diagnosis is made during small-animal consultations or how much of a role making a diagnosis plays in veterinary decision-making. Understanding more about the diagnostic process will help direct future research towards areas relevant to practicing veterinary surgeons. The aim of this study was to determine the frequency with which a diagnosis was made, classify the types of diagnosis made (and the factors influencing these) and determine which specific diagnoses were made for health problems discussed during small-animal consultations. Data were gathered during real-time direct observation of small-animal consultations in eight practices in the United Kingdom. Data collected included characteristics of the consultation (e.g. consultation type), patient (e.g. breed), and each problem discussed (e.g. new or pre-existing problem). Each problem discussed was classified into one of the following diagnosis types: definitive; working; presumed; open; previous. A three-level multivariable logistic-regression model was developed, with problem (Level 1) nested within patient (Level 2) nested within consulting veterinary surgeon (Level 3). Problems without a previous diagnosis, in cats and dogs only, were included in the model, which had a binary outcome variable of definitive diagnosis versus no definitive diagnosis. Data were recorded for 1901 animals presented, and data on diagnosis were gathered for 3192 health problems. Previous diagnoses were the most common diagnosis type (n=1116/3192; 35.0%), followed by open (n=868/3192; 27.2%) then definitive (n=660/3192; 20.7%). The variables remaining in the final model were patient age, problem history, consultation type, who raised the problem, and body system affected. New problems, problems in younger animals, and problems raised by the veterinary surgeon were more likely to result in a definitive diagnosis than pre-existing problems, problems in older animals, and problems raised by the owner. The most common diagnoses made were overweight/obese and periodontal disease (both n=210; 6.6%). Definitive diagnoses are rarely made during small-animal consultations, with much of the veterinary caseload involving management of ongoing problems or making decisions around new problems prior to a diagnosis being made. This needs to be taken into account when considering future research priorities, and it may be necessary to conduct research focused on the approach to common clinical presentations, rather than purely on the common diagnoses made. Examining how making a diagnosis affects the actions taken during the consultation may shed further light on the role of diagnosis in the clinical decision-making process.

Stress in new graduates: can the profession do more to help?

Richard Halliwell and colleagues believe that it can, on the basis of a survey they conducted to assess the incidence of poor mental health and wellbeing in recent veterinary graduates, and workplace factors that might be associated with this.

Investigating preventive-medicine consultations in first-opinion small-animal practice in the United Kingdom using direct observation.

Preventive-medicine consultations account for a large proportion of the veterinary caseload and previous research has suggested these consultations are fundamentally different from those in which the animal is presented for a specific health problem. There has been recent controversy around some aspects of preventive medicine for cats and dogs, and the full health benefits of the preventive-medicine consultation remain unclear. The aim of this study was to compare characteristics of the consultation and the problems discussed during the consultation between preventive-medicine consultations and other types of consultations. Data were gathered during direct observation of small-animal consultations in seven first-opinion practices in the United Kingdom. Data collected included type of clinical examination performed, patient signalment, and details of all problems discussed (including whether the problem was presenting or non-presenting, new or pre-existing, who had raised the problem, body system affected and whether an action was taken). A two-level multivariable logistic-regression model was developed, with canine and feline patients at Level 1 nested within consulting veterinary surgeons at Level 2, and a binary outcome variable of preventive-medicine consultation versus specific health-problem consultation. A total of 1807 patients were presented, of which 690 (38.2%) presented for a preventive-medicine consultation. Dogs were the most frequently presented species (n=1168; 64.6%) followed by cats (n=510; 28.2%), rabbits (n=86; 4.8%) and patients of other species (n=43; 2.4%). The five variables remaining in the multi-level model were whether multiple patients were presented, patient age, clinical examination type, weighing and number of problems discussed. Species, breed, sex, neutering status and practice did not remain in the final model. Many non-presenting problems, including both preventive-medicine problems and specific-health problems, were discussed and acted upon during all types of consultations. Dental and behavioural non-presenting problems were discussed more frequently during preventive-medicine consultations compared with specific health-problem consultations. Preventive-medicine consultations represent an opportunity for veterinary surgeons to discuss other aspects of preventive medicine, and to detect and manage new and ongoing health problems. A greater evidence base is needed to understand whether detecting and managing underlying disease during the preventive-medicine consultation has a positive impact on lifelong patient health and welfare.

Quality of life assessment in domestic dogs: An evidence-based rapid review.

Assessment of quality of life (QoL) is an important, increasingly popular outcome measure in veterinary research and practice, particularly in dogs. In humans, QoL is commonly assessed by self-reporting and since this is not possible for animals, it is crucial that instruments designed to measure QoL are tested for reliability and validity. Using a systematic, replicable literature search strategy, the aim of this study was to find published, peer-reviewed instruments for QoL assessment in dogs and to assess the quality of these. CAB Abstracts and PubMed were searched in July 2013 using terms relevant to dogs, wellbeing and QoL. Inclusion and exclusion criteria were applied. When instruments were not published in full, authors were contacted to obtain them. Criteria were applied to assess the quality, validity and reliability of the 52 instruments obtained. Twenty-seven additional instruments used in peer-reviewed publications were not included because they had not been fully described in the publication or were not provided by authors upon request. Most of the instruments reviewed (48/52) were disease-specific rather than generic. Only four publications provided a definition of QoL or wellbeing. Only 11/52 instruments demonstrated evidence of assessing reliability or validity, and the quality of these instruments was variable. Many novel, unvalidated instruments have been generated and applied as clinical outcomes before it was known whether they measured QoL. This rapid review can be used to identify currently available and validated canine QoL instruments, and to assess the validity and quality of new or existing instruments.

Survey of the UK veterinary profession 2: sources of information used by veterinarians.

Access to the most up-to-date evidence is an important cornerstone for veterinarians attempting to practice in an evidence-based manner; therefore, an understanding of what and how information is accessed is vital. The aim of this study was to identify what resources the UK veterinary profession access and regard as most useful. Based on questionnaires received from veterinarians, the Veterinary Times was nominated as most often read journal or magazine by respondents (n=3572, 79 per cent). In Practice (n=3224, 82 per cent) and the Veterinary Record (n=165, 34 per cent) were seen as most useful by clinicians, and non-clinicians, respectively. Google was the most often nominated electronic resource by all respondents (n=3076, 71 per cent), with Google (n=459, 23 per cent) and PubMed (n=60, 17 per cent) seen as most useful by clinicians and non-clinicians, respectively. The abstract and conclusion sections were the most read parts of scientific manuscripts nominated by all respondents. When looking for assistance with difficult cases, colleagues were the common information choice for clinicians. Different sections of the veterinary profession access information, and deem resources useful, in different ways. Access to good quality evidence is important for the practice of evidence-based veterinary medicine, and therefore, researchers should think about disseminating their findings in a targeted way for optimal use by the profession.

Investigating common clinical presentations in first opinion small animal consultations using direct observation.

Understanding more about the clinical presentations encountered in veterinary practice is vital in directing research towards areas relevant to practitioners. The aim of this study was to describe all problems discussed during a convenience sample of consultations using a direct observation method. A data collection tool was used to gather data by direct observation during small animal consultations at eight sentinel practices. Data were recorded for all presenting and non-presenting specific health problems discussed. A total of 1901 patients were presented with 3206 specific health problems discussed. Clinical presentation varied widely between species and between presenting and non-presenting problems. Skin lump, vomiting and inappetence were the most common clinical signs reported by the owner while overweight/obese, dental tartar and skin lump were the most common clinical examination findings. Skin was the most frequently affected body system overall followed by non-specific problems then the gastrointestinal system. Consultations are complex, with a diverse range of different clinical presentations seen. Considering the presenting problem only may give an inaccurate view of the veterinary caseload, as some common problems are rarely the reason for presentation. Understanding the common diagnoses made is the next step and will help to further focus questions for future research.

Capturing the complexity of first opinion small animal consultations using direct observation.

Various different methods are currently being used to capture data from small animal consultations. The aim of this study was to develop a tool to record detailed data from consultations by direct observation. A second aim was to investigate the complexity of the consultation by examining the number of problems discussed per patient. A data collection tool was developed and used during direct observation of small animal consultations in eight practices. Data were recorded on consultation type, patient signalment and number of problems discussed. During 16 weeks of data collection, 1901 patients were presented. Up to eight problems were discussed for some patients; more problems were discussed during preventive medicine consultations than during first consultations (P<0.001) or revisits (P<0.001). Fewer problems were discussed for rabbits than cats (P<0.001) or dogs (P<0.001). Age was positively correlated with discussion of specific health problems and negatively correlated with discussion of preventive medicine. Consultations are complex with multiple problems frequently discussed, suggesting comorbidity may be common. Future research utilising practice data should consider how much of this complexity needs to be captured, and use appropriate methods accordingly. The findings here have implications for directing research and education as well as application in veterinary practice.

Survey of the UK veterinary profession: common species and conditions nominated by veterinarians in practice.

The practice of evidence-based veterinary medicine involves the utilisation of scientific evidence for clinical decision making. To enable this, research topics pertinent to clinical practice need to be identified, and veterinary clinicians are best placed to do this. The main aim of this study was to describe the veterinary population, the common species and conditions veterinary clinicians nominated they saw in practice and how much information clinicians perceived was available in the literature for these. A questionnaire was distributed to all Royal College of Veterinary Surgeons registered veterinarians agreeing to be contacted for research purposes (n=14,532). A useable response rate of 33 per cent (4842/14,532) was achieved. The most commonly seen species reported by vets were dogs, cats and rabbits followed by equines and cattle. Overall, skin conditions were most commonly mentioned for small animals, musculoskeletal conditions for equines and reproduction conditions for production animals. Veterinary clinicians perceived there was a higher level of information available in the literature for conditions in dogs, cattle and equines and lower levels for rabbits and guinea pigs. The results from this study can be used to help define the research needs of the profession to aid the incorporation of evidence in veterinary practice.

A descriptive review of the peer and non-peer reviewed literature on the treatment and prevention of foot lameness in cattle published between 2000 and 2011.

The aim of this study was to collate and review the peer and non-peer reviewed English language literature on the treatment and prevention of foot lameness in cattle published since January 2000. The study aimed to identify deficits in knowledge and areas of disparity between what is recommended in the field by veterinarians, foot trimmers and advisors and what has been substantiated experimentally. Peer reviewed literature containing original work was gathered by searching three databases. Papers were categorised and reviewed if they contained material on treatment or prevention. Non-peer reviewed clinical materials were collated from a range of sources. The materials were reviewed and categorised based on whether they recommended a range of possible treatment and prevention strategies. The peer reviewed data base contained 591 papers, of which 286 contained information on treatment or prevention. The vast majority of papers (258) concerned prevention; only a small number covered treatment (31) and of these only three contained information on the treatment of sole ulcers or white line disease. The number of intervention studies and trials was low; most papers on prevention were observational. Generally, lesion specific outcomes were not described making the findings of these papers difficult to use clinically. The non-peer reviewed material contained 46 sources; they varied significantly in regard to the treatments they advocated with some texts directly contradicting each other. Some aspects of prevention recommended in these sources seemed poorly supported by findings from the research literature. Well designed intervention studies are required to address these deficits.