Veterinary practice owners can change a belief into evidence

In today's brave new world of information dissemination, you'd think our veterinary patients would benefit from the flood of new and exciting medications and technologies the industry has to offer. But this is only partially true, as many of the drugs, protocols and procedures we use need to be either pared back or nurtured—what really delivers, and what overpromises results?

Writing in the July 19, 2012, issue of the New England Journal of Medicine, author Jeffrey Avon, MD, professor of medicine at Harvard Medical School, points out in "Two Centuries of Assessing Drug Risks" that some drugs and formulations can be dangerous. But how do we know which ones?

In the veterinary world, evidence-based medicine gets talked about a lot, but as Rod Bagley, DVM, head of clinics at Iowa State University, says, we actually live in the realm of belief-based medicine, not evidence-based medicine. We operate under the belief that this or that activity will help patients. Sitting in his office, he related stories to me from within his neurology specialty where evidence is just plain lacking to support many of the clinical activities and common practices in veterinary medicine today.

Certainly this conversation is a wake-up call to those of us on the front lines. It's also a message to academics, to people who get all their veterinary medical information from the Internet, and to veterinary examining boards trying to establish norms for the so-called "local standards of practice," which are used to pass judgment on veterinarians who must defend their actions before these state boards.

Track outcomes to gather data

Veterinarians are presented with abundant opportunities to collect evidence. In a year, a veterinarian may see anywhere from 2,000 to 10,000 patients. There are all sorts of repeating cases: ear problems, lameness, skin infections, cruciate injuries, cauda equina syndrome, seizures, abnormal lactate concentrations, fractures—and the list goes on. The literature, as Bagley notes, offers a confusing constellation of solutions to similar issues. So, to change a "belief" into "evidence," you have a simple tool at your disposal: green sheets. Unsure about something you're observing? Track your own data with green sheets.

To get started with the green sheet system, get bright-green lined paper and begin tracking issues on these sheets. Use one sheet to track one issue, and log cases daily. If your practice is paperless, no problem—you can use Excel spreadsheets or your practice software to track the same things. The issues we've studied in my practice are issues we've "green-sheeted."

For example, consider carprofen. This useful drug came into veterinary practices in the late 1990s to help with pain management. Here's what we did in my practice: We took 100 patients, prescribed carprofen and tracked them. A few of our patients experienced liver problems while receiving the medication, so we called the manufacturer to report this finding. The folks there advised us that liver problems were not an issue with this product. Shortly thereafter, carprofen-associated liver problems hit the front page of the Wall Street Journal. Now, when practitioners use carprofen, they monitor liver enzyme activities. Simple. It's the standard of care.

For ear infections, we compared two different ear medications and treatment plans. We assessed ear suction vs. a simple ear cleaning. Try this: Treat 100 cases with ear suction and another 100 cases with ear cleaning and then compare the data. Is one method clearly better? Our evidence points to suction working the best.

For chronic pain, we used green sheets to compare two different therapy plans: tramadol vs. pentazocine and naloxone (Talwin Nx). Our data showed that pentazocine and naloxone work best in most cases.

We've all read that 40 percent of ruptured cruciate knees involve meniscus tears. But only 10 percent of my practice's cases involve meniscus tears. How about those resorptive lesions on the roots of feline teeth? We always hear the statistic that 40 percent of cats have roots with these lesions. But only 10 percent of my cases have these lesions. Lactic acid for horse colic surgery prognosis? In the mid-1980s, my practice collected data on 40 colic cases in which the human assay for lactic acid accurately predicted the outcome. Boy, did that get whacked at the Western Veterinary Conference back then. Today, it's a standard veterinary in-house test.

Here are some more issues we've tracked with green sheets:

• Vaccines. We tracked vaccinated patients vs. disease incidence. Dogs that came to us with parvovirus infection were unvaccinated or undervaccinated or had owners who'd used over-the-counter vaccines from the feed store. None of them were more than 5 years of age. We also tracked leptospirosis vaccination vs. disease cases and didn't find leptospirosis cases in vaccinated dogs.

• Tick disease incidence. Fifty percent of the dogs in my locale have antibodies for Rocky Mountain spotted fever and 50 percent have Ehrlichia antibodies. This is important because many in-clinic tests do not test for Rickettsia rickettsii, so now we know to always test for it.

• Immune nasal diseases. Niacinamide, tetracycline and other combinations are mostly ineffective.

• Erythrocyte sedimentation rates for dogs. We've tracked thousands of dogs with this test over the decades. If the corrected value is either very high or very low, we know we need to dig deeper because there could be a life-threatening issue hiding. This not-so-common test has a place on the front lines of clinical medicine.

The entire human medical field, including the exemplary Mayo Clinic in Minnesota, have conducted studies to track the outcomes of hundreds of thousands of patients on thousands of issues. A recent medical advisory reported: Skip the prostate-specific antigen (PSA) test. But Mayo Clinic countered with its own advice: Assess the situation individually, patient by patient—there is no one-size-fits-all approach to medicine. Use this methodology in your veterinary practice as a means to provide the best possible care to your patients.

Dr. Michael Riegger, DABVP, is the chief medical officer at Northwest Animal Clinic Hospital and Specialty Practice in Albuquerque, N.M. Contact him by telephone or fax at (505) 898-0407, riegger@aol.com, or www.nwanimalclinic.com. 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.