(This blog is a summary of my notes and impressions from the excellent talks presented by Drs. Jason Stull, Michelle Evason and Jason Coe at the OVMA conference 2024, for CASCMA’s Accessible Veterinary Care track.)
By Dr. Linda Jacobson, Toronto Humane Society/CASCMA
What is spectrum of care?
“Spectrum of care” (SpOC) is a term that was coined in Stull et al’s influential 2017 paper.1 This approach to patient care is advocated as a way to expand access to veterinary care in the face of escalating cost and other barriers. In the paper, the authors state: “Veterinarians have a wide spectrum of diagnostic and treatment options they can provide for their patients.”
SpOC is a departure from the concept of “best practices” or the so-called “gold standard”, which are taken to mean some type of “ideal” care. Clearly, there is no one-size-fits-all model of care for pets whose clinical presentation, temperament, life-stage, size and co-morbidities vary so widely, nor for their carers, whose income, location, culture, personal and emotional lives and life experiences differ so markedly from one another.
“Standard of care”, or SOC, is a minimum acceptable level of care, that can and should influence SpOC decision-making. However, it is important to distinguish this concept from the so-called “ideal” care that it is often, erroneously, confused with. An evidence-based approach to SpOC is essential, in order to provide reasonable care options and justify clinical approaches. Evidence-based veterinary medicine (EBVM) is best-available or best-relevant evidence, recognizing that we do not always have good or strong evidence, and so must use this in conjunction with clinical expertise and judgment. This online module www.ebvmlearning.org was recommended by the speakers.
The American Association of Veterinary Medical Colleges is currently working on incorporating SpOC into veterinary curricula, a welcome and important initiative.
How to use evidence to support SpOC approaches
It’s not necessary to reinvent the EBVM wheel – there are many evidence-based consensus statements and guidelines out there, as a starting point for decision-making. (I [LJ] would just caution that not all of them are as evidence-based as one might wish, and not all of them are “SpOC-friendly”.) There are also excellent short-cuts on Bestbetsforvets, which has succinct evidence summaries on a number of topics.
Dr. Stull demonstrated rapid literature searches to find evidence for clinical approaches. Ask a relevant, answerable question; search the literature; appraise the literature; apply the information; and assess results. He demonstrated the PICO(T) approach, whereby a question is formulated using the:
Patient/population/problem
Intervention/exposure/test
Comparison of interventions
Outcome [measured/desired]
(Timeframe [relevant to patient/client])
For example, when trying to provide SpOC options for a dog with parvoviral enteritis, the question might be:
“In dogs with CPV enteritis, what are the outcomes (survival rates) with inpatient vs outpatient treatment?”
Searches are best done in PubMed, which does not tailor the result to your previous search histories, the way Google Scholar does. Searches are structured as “AND/OR”, with terms in parentheses as needed, and * to allow flexibility – for example, “dog” will get you dog, dogs, doggie, doggy. The search for the CPV question could be:
(DOG*) AND (PARVO* OR CPV) AND (OUTCOME OR PROGNOSIS OR SURVIVAL) AND (INPATIENT OR OUTPATIENT) AND (TREATMENT)
The hits for this particular search landed on 3 evidence-based papers on the subject – the abstracts, at least, can quickly be scanned for results and direction in the moment. To create SOPs, most papers are available online now, and should be read and evaluated in more detail.
What to do with this information? Communication 101!
In shelter scenarios, sometimes the veterinarian can simply act on information obtained. At other times, it could be used to develop new protocols/SOPs, or to argue for a change in approach to a condition or treatment.
In client-facing settings, we are required to obtain informed consent. This particularly applies to novel or unusual approaches, especially where a different approach is considered the norm, or is recommended in well-known guidelines.
Communication is key in SpOC conversations. It’s necessary to understand the person, animal and environment, and to do this, it’s important to use (truly) open-ended questions. Most of us were trained to use closed-ended questions, so some internal re-training is needed. Dr. Coe gave these examples:
Walk me… Tell me… What…
- “Walk me through what a typical day looks like for Harley and you.”
- “Tell me about people and animals Harley commonly interacts with.”
- “Tell me what most concerns you have today.”
Dr. Coe’s research showed that clients want options presented, with some guidance from the veterinarian. Presenting options also makes the veterinarian appear more trustworthy. The context of options is the prognosis, pros and cons, and cost.
Conversations around cost are important, and can be difficult to navigate. Communication tools that help with cost conversations are also relationship-building statements:
- Empathy statements (showing understanding): “I can see that…”
- Partnership statements: “we”, “together”
- “I wish” statements
SpOC decisions are shared decisions. A three-talk model can work well:
- Team talk –“us”, “together”, “let’s”. These talks work best if both the veterinarian and technician participate.
- Option talk
- Decision talk
The value matrix
Clients want to know about the impact of treatment options on their pet. The value matrix, which is taught by Dr. Coe, helps them to understand the pros and cons of different options. The matrix is a table, with options along the side and benefits (to the pet, to the client, and in terms of cost) along the top. Dr. Coe emphasized that there is no “one-size-fits-all” categorization and the matrix will look different in different contexts. For example, pain or life-threatening risks woud factor in to some situations but not others.
Each conversation and matrix must take into account factors regarding the client, veterinarian, geography and clinic. For example, some general practice veterinarians may be competent to perform cruciate surgeries and some may not.
Talking options in the trenches
Dr. Evason walked us through some case examples that illustrated the techniques from the previous talks. One example was a dog with parvoviral enteritis, already mentioned above. For this dog, the options presented were Outpatient care and Inpatient care, and the Benefits/Factors were Survival based on research, Resolve dehydration, Monitoring for complications, Improve quality of life, Less time/labour-intensive, and Estimated cost. This provided a clear and visual reference to help the client to make an informed decision.
This was an excellent track that was really informative and provided attendees with concrete tools to practice SpOC and help advance accessible veterinary care. CASCMA is very grateful to our three wonderful speakers!
With thanks to our Track Sponsors at OVMA 2024:
Antech
Ontario Veterinary College
Ctrl + F Inc.
References:
1. Stull JW, Shelby JA, Bonnett BN, et al. Barriers and next steps to providing a spectrum of effective health care to companion animals. J Am Vet Med Assoc. 2018;253(11):1386-1389.
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