6th EBVMA Symposium

Christopher Longhurst, MD, MS, DABP (Pediatrics), DABPM (Clinical Informatics)

Clinical Associate Professor, (Pediatrics – Systems Medicine; General Pediatrics; Medicine – Biomedical Informatics Research), Fellowship Director, Clinical Informatics; VP of Analytics; Chief Medical Information Officer (CMIO), Stanford Children’s Health; Lucille Packard Children’s Hospital, Stanford School of Medicine, Stanford University

Human pediatric medicine shares many similarities to veterinary medicine such as the intrinsic nature of patient proxies (e.g. parents, pet owners or herd managers) and the characteristics of reporting and evaluating outcomes of interventions in a clinical environment or research study. Another is the relative paucity of good prospective research. There is a heavy reliance on evidence at levels III through V, especially case studies or expert opinion. Dr. Longhurst will share work he and his colleagues have highlighted in Evidence-Based Medicine in the EMR Era (PDF); NEJM, 10 Nov 2011; 365:1758-1759, which demonstrates the use of an institutional (Stanford Childrens Health) clinical data repository built from a robust electronic medical record system, to perform patient cohort analysis where evidence from publications may be lacking .

David Ramey, DVM

Equine Medicine; Contributor, Science-Based Medicine Blog; Author:

Ethical treatment of animals is more than merely a matter of causing no harm and pleasing the client. A veterinarian has a moral and ethical obligation to provide treatment for which there is good evidence of effectiveness. Indeed, society desires and expects that effective treatments are being provided. For any treatment, establishing proof of efficacy as well as potential risks and benefits is an ethical requirement.

Robert Larson, DVM, PhD, DACT, DACVPM (Epidemiology), DACAN

Professor, Production Medicine; Edgar E. and M. Elizabeth Coleman Chair Food Animal Production Medicine; Executive Director, Veterinary Medical Continuing Education; College of Veterinary Medicine, Kansas State University

The human mind is pretty good at properly linking cause-and-effect when the initiating cause and outcome are easily detected with human senses, straightforward with no interactions, and closely spaced in time, location, and magnitude. However, if either a causative factor or its outcome is undetectable by human senses aided by technology; or if multiple causes either must or can interact to bring about the outcome, the human mind makes many erroneous conclusions. Many of these problems exist in veterinary medicine, in that nearly all causes of disease and repair are completely outside the ability of human senses to detect even when aided by advanced technology, the time-frame between a causative factor and a clinically important outcome can be prolonged (with many other visible factors occurring in the interim time), and very slight or undetectable changes in homeostatic mechanisms can result in profound changes in perceivable disease or repair outcomes (with more-easily detectable – but wholly non-influential changes occurring prior to disease or repair outcomes). Fortunately, veterinary medicine can be a data-rich area of scientific investigation. Even though many of the factors affecting animal disease and repair are difficult or impossible to detect, the outcomes (recovery, length of life, improved growth, etc.) are readily measurable and occur within reasonable time frames. In a science like veterinary medicine, our investigations of nature can be data-driven because of the relative ease of collecting clinically important outcome data.

Erin E. Kerby, MS

Veterinary Medicine Librarian; Assistant Professor, University Library, Veterinary Medicine Library, University of Illinois at Urbana-Champaign

Many professionals working in the field of veterinary medicine have recognized the need to improve the quality and reliability of published research, but little progress has been made on this front in the past decade. While the researchers themselves could do much to improve the situation, there are other stakeholders involved who need to step up to the plate. This presentation puts forth the idea that veterinary journal publishers and editors need to be more clear and rigorous with their policies and author instructions, specifically with regards to research data. An article recently published in BMC Veterinary Research suggests that “wider adoption of reporting guidelines by veterinary journals would improve the quality of published veterinary research.” Such an improvement would allow for more effective appraisal of the literature and accordingly increase the quality of evidence available and used in veterinary practice. These reporting guidelines could be further strengthened by a policy for the inclusion and/or sharing of research data. Several recent governmental mandates and initiatives at the federal level have caused entities such as NSF (National Science Foundation) and NIH (National Institutes of Health) to begin creating policies requiring grant applicants to create research data management plans. Despite this, there has been little incentive so far for veterinary researchers to create data management plans or to make their data more widely available because many grant recipients do not reach the funding threshold for the NSF and NIH requirements. Although a handful of veterinary journals currently have some sort of research data policy, wider adoption would create more incentive for the researchers and authors, improve the peer review process, and contribute to better quality published research

Kenichiro Yagi, BS, MS¹ and David Liss, BA, RVT, VTS (ECC, SAIM), CVPM²

[1] PetEd Veterinary Education and Training Resources; ICU Supervisor, Blood Bank Manager, Adobe Animal Hospital, Los Altos, California, United States
[2] Program Director- Veterinary Technology at Platt College, South Pasadena, California, United States

The RECOVER initiative has influenced many to evaluate their perspective on evidence-based practices in veterinary medicine. The Nursing Standard Committee of the Academy of Veterinary Emergency and Critical Care Technicians is currently working on creating evidence-based guideline for nursing practices employed in the veterinary ECC. The process is modeled after the RECOVER initiative process described, with indirect mentorship from Dr. Daniel Fletcher (a co-chair of the RECOVER committee). Current work is focused on urinary catheter placement and maintenance, with a group of approximately 20 veterinary technician specialists from a variety of background asking practical nursing questions and evaluating the evidence available through literature. This is the first effort we are aware of driven completely by veterinary technicians to produce practical guidelines for technicians, and hope to be one of the first of many fruitful guidelines to be established. Such an effort has some of its unique challenges to be overcome, including the state of the veterinary technician profession and familiarity with evidence searches and critical analysis of levels of evidence.

Katie Waine¹*; Chris Hudson¹; Rachel Dean, BVMS PhD DSAM (Fel) MRCVS¹; Jon Huxley¹ and Marnie Brennan, BSc (VB), BVMS, PhD¹

[1] School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Sutton Bonington, Loughborough, Leicestershire LE12 5RD, United Kingdom

Clinical audit has been used by the medical profession for nearly 30 years, yet is still a relatively new concept in farm animal veterinary practice. The Royal College of Veterinary Surgeons (RCVS), the governing veterinary organisation in the UK, now stipulate that individual veterinary surgeons and practices under the RCVS Practice Standards Scheme should be carrying out audit as part of their clinical governance to improve clinical standards. Types of practice, such as farm animal practice, requiring visits to individual premises as opposed to seeing cases within a hospital environment have additional challenges when conducting clinical audit. There are no current guidelines advising farm animal veterinary surgeons on how best to run clinical audit in practice. This presentation will discuss how clinical audit could be used in farm animal veterinary practice.

* Speaker

Natalie Robinson¹*; Marnie Brennan, BSc (VB), BVMS, PhD¹; Malcolm Cobb¹ and Rachel Dean, BVMS PhD DSAM (Fel) MRCVS¹

[1] School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Sutton Bonington, Loughborough, Leicestershire LE12 5RD, United Kingdom; * Speaker

Miles Theurer, DVM, PhD

Kansas State University, United States

Vaccination of cattle is routine procedure in the beef industry with the goal to suppress and delay the severity of bovine respiratory disease complex (BRDC). Bovine respiratory disease is a multi-factorial disease with one of the primary causes due to viral or bacterial infection. We performed a systematic review and meta-analysis to evaluate the efficacy of vaccinating cattle with commercially available viral and bacterial agents to mitigate the effects of BRDC. Determination of clinical efficacy from induced-disease challenge models requires caution as induction models are different from natural exposure. The published literature provides some guidance for veterinarians, but does not provide definitive recommendations for which viral and/or bacterial components are necessary for a vaccination program. This presentation will discuss the outcomes of this review as well as the challenges in the design, execution and publication of systematic reviews in veterinary medicine.

Robert Larson, DVM, PhD, DACT, DACVPM (Epidemiology), DACAN

Professor, Production Medicine; Edgar E. and M. Elizabeth Coleman Chair Food Animal Production Medicine; Executive Director, Veterinary Medical Continuing Education; College of Veterinary Medicine, Kansas State University

Critical thinking is a process, and as such is never completed. Critically thinking about a clinical problem involves repeating the steps of gathering information, evaluating that information, reflecting on the information and coming to tentative conclusions. Because no single study can fully address most clinical questions and because every study has limitations either in internal and/or external validity, using scientific studies to enhance clinical decision-making requires combining different pieces of evidence of varying strengths. While gaining competence in each step of the critical thinking process requires education, skill, and experience, probably the most difficult to master is to reflect deeply about what is known and what is unknown and how to tie multiple pieces of information and evidence together.

Robert Larson, DVM, PhD, DACT, DACVPM (Epidemiology), DACAN

Professor, Production Medicine; Edgar E. and M. Elizabeth Coleman Chair Food Animal Production Medicine; Executive Director, Veterinary Medical Continuing Education; College of Veterinary Medicine, Kansas State University

Well-designed studies differ from clinical experience because explicit constraints are implemented to control for sources of bias. Clinical experience is particularly prone to bias because the same person provides and then evaluates interventions. Biases that occur commonly, and often inadvertently, when relying on clinical experience are typically grouped into categories of selection bias, information bias, and confounding.

Observations in clinical settings are plagued by selection bias because although this bias is a crucial flaw if one wants to compare interventions, it is perfectly appropriate and beneficial when applied to clinical case management. Essentially, selection bias occurs when animals with certain signalment, history, or physical examination findings are treated differently than animals without those case characteristics. While clinically reasonable, this practice prevents any attempt to accurately compare alternative risks or treatments.

Similarly, information bias is very common in clinical case management because we intentionally gather different types and amounts of information about different animals. For example, it is reasonable to observe some animals more closely, under different circumstances, or for longer periods of time than other animals. However, this bias can lead to incorrect associations with either disease-causation or treatment factors.

Ronette Gehring, BVSc, MMedVet (Pharm), MRCVS, DACVCP

Associate Professor, Clinical Pharmacology, Kansas State University

The United States Pharmacopeial Convention (USP) monographs contain Evidence Tables that summarize all items of the literature pertaining to contentious label and extra label use of drugs for species-specific indications in clinical veterinary practice. These have now been digitized with support from an EBVMA grant and are available through a web-enabled database. The objective of this presentation is to introduce the methods of making evidence assertions for the clinical indication and use of these drugs, to introduce this database to the evidence-based veterinary medicine community, and encourage participants to become involved in updating and expanding this online resource.

* Roy Montgomery Research Award Winner

Erik Fausak, MA, MS

Instructor, Bel-rea Institute of Animal Technology; Online Veterinary Athenaeum

Evidence-Based Veterinary Medicine is contingent on one important idea, that you have access to the evidence to evaluate it. The following presentation is about how to utilize freely available resources for the limited resources of a private practitioner. Review the utilization of robust databases that are freely available: PubMed and Google Scholar. Additionally, the oft overlooked resource in your neighborhood often has many veterinary resources, your local library. This presentation or tutorial is about how to utilize these databases and public libraries to access the resources you want without leaving the comfort of your clinic.

Rachel Dean, BVMS PhD DSAM (Fel) MRCVS & Marnie Brennan, BSc (VB), BVMS, PhD

Centre for Evidence-Based Veterinary Medicine, Faculty of Medicine & Health Sciences, University of Nottingham, United Kingdom

The Centre for Evidence-based Veterinary Medicine (CEVM) was established at the School of Veterinary Medicine and Science at the University of Nottingham in 2009. The CEVM is now a team of 15 veterinary and non-veterinary researchers dedicated to promoting the awareness and use of the EVM principles in veterinary practice. Since it started the CEVM has identified aspects of Evidence Based Medicine (EBM) that can be adapted for the veterinary profession to help practitioners integrate evidence into their clinical decision-making. The CEVM uses both qualitative and quantitative methods and works directly with the profession at every available opportunity.

The CEVM has four core areas: Population Research, Evidence Synthesis, Practice-based Research and Education/Information Exchange. The population research involves both animals and their carers/owners as well as veterinary surgeons themselves and includes the only shelter medicine research programme in the United Kingdom. The CEVM has created resources such as Best BETs for Vets (www.bestbetsforvets.org) and VetSRev (www.nottingham.ac.uk/cevm/evidence-synthesis/systematic-review/vetsrev) as part of the evidence synthesis work. They are both freely available to practising veterinary surgeons and updated on a monthly basis. Our practice-based research has involved working closely with first opinion veterinary practices on research projects to help us prioritise the evidence needs of practices. An international EVM survey of the veterinary profession was also undertaken and the results are being assimilated. Education and information exchange is vital to the work of the CEVM and has involved teaching veterinary undergraduates as well as practitioners and has enabled us to work towards developing the most appropriate methods to best deliver evidence to practice.

The aim of this presentation is to highlight the development and outputs of the CEVM since EBVMA 2010 and highlight the challenges and successes of the CEVM to date.

Steve Budsberg, DVM, MS, DACVS

Professor, Department of Small Animal Medicine Surgery; Director of Clinical Research; College of Veterinary Medicine, University of Georgia, United States

It is clear over the last decade that evidence based medicine (EBM) advocates have focused on promoting the concepts and ideals of EBM as well as teaching the skills needed to use it efficiently and effectively. With this knowledge and education there has been emergence of a significant number of perceived barriers that seem to prevent the clinician from implementing EBM. Remember, at its’ core EBM attempts to take the results of population studies and apply them to an individual patient. This is in stark contrast to traditional medical practice in which clinical experience (often from individual patients) is commonly used to define and defend the treatment of an entire group of patients with a similar problem. Thus it is apparent that promoting this paradigm shift must emphasize the fact that these data must however be combined with the knowledge of the individual patient/client and the experience of the clinician. When clinicians read and think about evidence based medicine (EBM), thoughts that often come to mind are “how does this really affect me and if I want to use EBM, how I can do this in my daily practice?” It is important to remember the evidence (data), by itself, does not make a decision for you, but it can help support the patient care process. We must now focus on the process of encouragement of collaboration by means of positive and safe communication and shared learning across career stages to overcome these barriers. Recent studies suggest that these types of proactive steps will facilitate the uptake of EBM and reduce cognitive and affective biases in clinical decision-making. Thus, we need look critically at all the pros and cons of EBM and move forward, not as evangelical preachers or high minded academics but as colleagues and mentors to work to improve the use of all the data available when treat our patients. In the next few years, as clinical trial data continues to increase, we must guide and instill in individuals at all levels of their professional careers a sense of how EBM can benefit them when used judiciously and correctly.

Panel presentation

This was a one hour review by organizers and attendees of RCVS Knowledges’ 1st Evidence-Based Veterinary Medicine Network Conference held 23-24 October, 2014 in Windsor, United Kingdom. Conference website (Warning: Adobe Flash based website)