Are your rabies ratios on target?
Necropsy is one of a clinician's best teachers; are we staying sharp?
We can't diagnose what we do not suspect.
And this degree of suspicion is central to any diagnostic plan. Yet, a weakness in veterinary medicine is the lack of knowledge about the relative incidence of various diseases and conditions. While some overall data is becoming available, knowing disease frequencies among your client base would be very valuable information.
Certainly, we can predict that dogs on specific therapy will have problems. We can predict certain medical needs like ovariohysterectomies and orchiectomies in dogs and cats. The relative need for vaccines can be determined for each practice. Clearly all mammals in risk situations need rabies protection.
We can find an inventory of the variety of conditions that we might see in our practices within the indexes of internal medicine and surgical textbooks. Yet, these texts cannot tell us about the relative incidence of diseases and assorted conditions near us.
Most veterinarians wouldn't argue that hyperthyroidism is the most common endocrine condition in the geriatric cat.
Table 1 Rabies ratio targets/proposed monthly per veterinarian
But what endocrine disorders are most common in the dog? Is it thyroid, Addison's disease, Cushing's disease or something else?
It would be most helpful for veterinary clinicians to have a ready, accurate list of the 50 most common diseases seen in veterinary clinical medicine.
Now we are not talking "most commonly diagnosed" diseases, we are talking "most common" diseases.
So each week, we do not know what was missed this week in the clinical diagnostics of our practices.
And we must all admit to having certain favorite interests like endocrinology, orthopedics, oncology or the all-time favorite, cardiology.
Our assorted favorites can dominate our differential lists. Consequently, the diagnostics then can skew our personal data toward our favorite subjects.
So where to begin?
AAHA recently recognized the issue of "incidence of diseases" and is seeking diagnostic codes for the profession, which is a nice reactive step. Diagnostic codes will help us determine what is currently recognized in the field, but this step will not tell us the relative incidence of conditions.
When it comes to arthritis, do we know which are the most common problems?
In Boxers, do we know the incidence of cardiomyopathy?
In cats, do we know the incidence of hypertrophic cardiomyopathy versus hypertension?
When we look at dermatology cases, do we know the incidence of immune diseases relative to each 100 cases walking in our front doors?
How many electrocardiograms do we need to read per month to stay sharp?
Yes, we need to pay attention to phenobarbital levels in pets, but are we tracking that data?
And we know that protein in the urine has become a hot topic — but what percent of the time do we actually need to proceed to urine protein quantification?
Society for Veterinary Ethics doles out essay award
Of all the lame dogs coming into our clinics, what percent will have cruciate injuries? The Wall Street Journal recently made the subject of canine cruciates a front-page story.
How many complete neurological examinations do we need to do each month to be tuned up enough to at least recognize that a case needs to be referred?
And speaking of referrals, how many per month could we be making?
In dogs with anal gland problems, we can drain them over and over, but how often do we need to consider removal of these offending tissues?
Necropsy is one of a clinician's best teachers, so how many do we need to do to stay sharp?
Tracheal collapse has become a garbage diagnosis — so how many cases are really chronic bronchitis?
There is a lot of talk about regarding pre-op tests these days, so how often can we do an ACT bedside bleeding test as part of a pre-op assessment?
The list of topics seems endless.
The point? Rabies ratios targets can help. Table 1 is an updated Rabies Ratio Targets (RRT) worksheet, originally published 15 years ago in my book "Management for Results".
The basic concept of RRT comes from the human side of medicine — in particular lessons learned from the tracking of human data at the Mayo Clinic in Minnesota.
The incidence of disease, conditions and the use of preventive health services can be tracked.
To track these issues we need a concept of what is happening per 1,000 patients.
So if we have 1,000 patients, then we expect
- 1,000 stool specimens per year
- 1,000 heartworm tests per year
- 1,000 pets covered by rabies vaccines.
Remember that preventive health care is easy. It's not so easy to provide for the medical and surgical needs of 1,000 patients.
In a routine practice with normal age demographics, 30 percent of pets have dental disease. And, if we expect each to benefit from two dental cleanings per year, then we should plan on 600 dentals per year, which is about 50 per month.
With hyperthyroid disease in a typical practice with 50 percent cats, we would expect about 20 of those cats to have this disorder.
To find this disorder, we need to test more than we suspect. So in round numbers, we need to test at least one per week.
A big surprise for us comes in the musculoskeletal/neurology group, Cauda Equina Syndrome. In our hands, the most common clinical arthritic condition is Cauda Equina Syndrome (CES) in dogs and cats.
We suggest that for each 1,000 pets in a typical demographic small animal middle-market practice, perhaps 5 percent all have CES. Data also supports that this is a commonly overlooked condition in small animal practice.
And when we compare, we are likely to see at least five CES cases to the more popular disease of hip dysplasia arthritis.
Consider adrenal disease. Addison's disease has been declared the most under-diagnosed endocrine disorder in the United States. So, what is the incidence of Addison's when compared to, say, Cushing's? We propose that maybe as many as 3 percent of all dogs have these disorders. So, for each 1,000 pets in a 50 percent canine practice, about 15 pets have adrenal problems.
The information in Table 1 is a preselected list of key conditions from within the overall picture of health of dogs and cats.
The 1,000 patients target is broken into 12 months of 100 per month.
With these key items listed, the clinician becomes sensitized to the various different systems: musculoskeletal, external, neurologic, sensory, cardiovascular, hematolymphopoietic, respiratory, urogenital and gastrointestinal.
How to use rabies ratio target list
Rule 1: The goal is to run a test if there is a 10 percent suspicion level for a disease.
Rule 2: Post the Rabies Ratio Targets in the office.
Rule 3: Mark it daily.
Rule 4: Remember that each day one will be reminded to look at outpatients globally for these items.
Rule 5: Make it a daily habit to review the differential list section in Rhae Morgan's Handbook of Small Animal Medicine.
Dr. Michael Rigger is the chief medical officer at Northwest Animal Clinic Hospital and Specialty Practice. Contact him at www.northwestanimalclinic.com, Riegger@aol.com, telephone and fax (505) 898-0407. Find him on AVMA's NOAH as the practice management moderator. Order his books "Management for Results" and "More Management for Results" by calling (505) 898-1491.