Pet-Specific Care for the Veterinary Team. Группа авторов
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the clinician to be transparent about this with pet owners and to provide the information needed for fully informed consent.
2.1.5 How Does EBVM Work in Practice?
Ideally, EBVM methods should be a core part of veterinary medical training. The habits of identifying specific information needs and then finding and critically evaluating scientific evidence are extremely useful once established, but some formal training and practice are required to develop these habits.
The basic steps in the process of integrating research evidence into clinical decision making are as follows.
1 Ask specific, answerable questions.
2 Locate relevant evidence.
3 Assess the reliability and applicability of this evidence.
4 Draw a conclusion.
5 Assign a level of confidence to this conclusion.
This is an iterative process that must be repeated as information needs change and new evidence becomes available.
Of course, in a busy clinical practice it is not possible to apply such a formal method to every question for every patient in real time. The goal of applied EBVM is to develop a personal knowledge base derived from explicit, critical assessment of scientific evidence which the veterinarian can then apply to individual patients as appropriate, guided by the unique circumstances of each case, the goals and resources of the owner, and the judgment of the clinician. The meaningful difference between this process and opinion‐based medicine is that the knowledge base a clinician uses to make recommendations is not a haphazard collection of information gleaned from sources of uncertain reliability but a set of conclusions with known provenance and a clearly established degree of uncertainty.
Figure 2.1.1 illustrates common types of evidence used to guide clinical decisions. Such evidence pyramids are helpful in establishing a degree of confidence in our conclusions. A recommendation based only on low‐quality evidence at high risk of bias, such as clinical experience or expert opinion, should be qualified, and the inherent uncertainty of the supporting evidence must be disclosed to clients. Recommendations based on more reliable evidence, such as systematic reviews or clinical practice guidelines, can be presented with much greater confidence.
Figure 2.1.1 An evidence pyramid illustrating the variable reliability and risk of bias of different types of scientific evidence.
Clinicians must always use their individual judgment in drawing conclusions from scientific evidence and applying these to specific patients. However, the hierarchy of evidence makes it easier for veterinarians to identify the reliability of specific types of evidence and of conclusions based on this evidence and to then communicate the degree of uncertainty to pet owners.
Charlie is a 4‐year‐old neutered male Cavalier King Charles spaniel. His owner is seeking your opinion because another veterinarian recently told her Charlie has a heart murmur. The owner was told that because Charlie is young and has no clinical issues, there is no need to do any tests or start any treatment. However, her breeder has told her that Charlie should be on a medication called “enalapril.”
You are aware of the breed predisposition for mitral valve disease (MVD) in Cavaliers, and you tell the owner that this is the most likely diagnosis based on Charlie's signalment and physical exam findings. You have also recently reviewed the American College of Veterinary Internal Medicine guidelines for diagnosis of MVD [1], and you explain that Charlie has stage B MVD, meaning he has a murmur but no clinical signs.
You explain that while enalapril was once commonly recommended for dogs with preclinical MVD based on low‐level evidence (pathophysiological reasoning and clinical experience), higher quality evidence (clinical trials) [2, 3] has since shown that it does not delay the onset of congestive heart failure (CHF), so you recommend against this medication.
In association with another case, you recently investigated whether there are any useful treatments for dogs with stage B MVD. You discovered the EPIC study, a high‐quality clinical trial investigating the use of pimobendan in dogs with MVD [4]. This trial included a lot of Cavaliers, so you believe the results are applicable to Charlie. You tell the owner that this study found a dramatic delay in the onset of CHF in dogs using pimobendan if they were in stage B2 MVD, meaning they had enlarged hearts. You explain that you could stage Charlie using radiographs, but the EPIC study suggested measurements from an echocardiogram are more reliable, so you recommend this test.
The owner is impressed with your detailed scientific knowledge and happy to have something she can do to keep Charlie healthy. You arrange an echocardiogram and agree to manage Charlie's MVD based on the results.
EBVM is a comprehensive system for producing and disseminating reliable scientific evidence and for integrating this evidence into clinical decision making.
EBVM methods make identifying, finding, and using needed information easier for veterinarians.
Integrating research evidence with clinical experience and the needs and resources of owners helps reduce medical error and supports more proactive, effective pet‐specific care.
EBVM also facilitates our ethical obligations to provide the most effective care for patients and to support informed consent for clients by providing the most accurate information and a clear assessment of relevant uncertainty.
EBVM helps veterinarians provide better care and better client communication with greater confidence and less time and effort.
References
1 1 Atkins, C., Bonagura, J., Ettinger, S. et al. (2009). Guidelines for the diagnosis and treatment of canine chronic valvular heart disease. Journal of Veterinary Internal Medicine 23 (6): 1142–1150.
2 2 Atkins, C.E., Keene, B.W., Brown, W.A. et al. (2007). Results of the veterinary enalapril trial to prove reduction in onset of heart failure in dogs chronically treated with enalapril alone for compensated, naturally occurring mitral valve insufficiency. Journal of the American Veterinary Medical Association 231: 1061–1069.
3 3 Kvart, C., Haggstrom, J., Pedersen, H.D. et al. (2002). Efficacy of enalapril for prevention of congestive heart failure in dogs with myxomatous valve disease and asymptomatic mitral regurgitation. Journal of Veterinary Internal Medicine 16: 80–88.
4 4 Boswood, A., Häggström, J., Gordon, S.G. et al. (2016). Effect of pimobendan in dogs with preclinical myxomatous mitral valve disease and cardiomegaly: the EPIC study – a randomized clinical trial. Journal of Veterinary Internal Medicine 30 (6): 1765–1779.
Recommended Reading
1 Best BETs for Vets – A collection of CATs for veterinary species. http://bestbetsforvets.org
2 Cockroft, P. and Holmes, M. (2003). Handbook of Evidence‐Based Veterinary Medicine, 210. Oxford: Blackwell.
3 McKenzie, B.A. (2014). Veterinary clinical decision‐making: cognitive biases, external constraints, and strategies for improvement. Journal of the American Veterinary