Evidence collection19 August 2020

Remote consulting

Introduction

The Coronavirus pandemic has led to many changes in veterinary practice, including the need to be able to provide veterinary services remotely. While the technology to provide remote consultations was already available prior to the pandemic, the provision of such services has been controversial.

However, the need for social distancing imposed by the government in response to the pandemic made it necessary for many practices to provide some level of remote consultation to their clients. This may include triage of cases to assess whether they need to be seen, as well as the management and monitoring of cases that might normally be seen at the surgery.

Despite the easing of restrictions and return to a more normal level of service, it is likely that remote consultations may still be needed to manage workflow, to provide veterinary care to the animals of owners who are self-isolating or shielding, or in the case of re-imposition of local or national restrictions.

While there is little published evidence on the safety and efficacy of remote consultation, this Spotlight feature highlights some published papers, which may provide useful points for consideration for those providing remote consultations.

Remote consultations

Roca, R.Y. and McCarthy, R.J. (2019) Impact of telemedicine on the traditional veterinarian-client-patient relationship. Topics in Companion Animal Medicine, 37, 100359. https://doi.org/10.1016/j.tcam.2019.100359

This paper reports on a multi-level survey that was sent to pet owners who used a popular United States telemedicine website over a 5-month period. A total of 398 responses (out of a possible 6,000) were obtained.

The majority of those responding (76.2%) had an existing traditional care veterinarian, and of these, 91.9% would use alternative methods of communication (phone, text or video) if provided. The remainder (23.8%) of owners did not have a traditional care veterinarian and requested referral to one. Most online consultations (60.0%) resulted in recommendation to follow up with a traditional care veterinarian, and 68.8% of owners did so. During follow-up owners felt better informed (89.3%) and better able to communicate (86.8%) with their traditional care veterinarian. Traditional care veterinarians agreed with the telemedicine service recommendation in 82.4% of cases. The most common reason for owners not following up with a traditional care veterinarian was financial limitation.

The authors conclude that the results of this survey suggest that the addition of telemedicine to the traditional Veterinary-Client Patient Relationship is viewed by owners as almost uniformly positive. However, it is noted that the limitations of telemedicine consultations including the lack of face-to-face interaction with a client and hands-on contact with a patient meant that the majority of telemedicine consultations resulted in the recommendation to follow up with a face to face consultation (60.0%).

Widmar, N. O. et al. (2020) Online procurement of pet supplies and willingness to pay for veterinary telemedicine. Preventive Veterinary Medicine, 181, 105073. https://doi.org/10.1016/j.prevetmed.2020.105073

This paper reports on an online survey of 1245 pet owners carried out in the United States. While part of the survey related to the demographics and procurement of pet supplies it also included a “choice experiment” asking about owners about their willingness to pay for telemedicine consultations at five different price points. It was made clear that the service, which would at least involve a phone call and could include video, was intended to provide information about further steps in the pet’s care and that an in person examination/office visit may still be needed. Both dog and cat owners indicated a willingness to pay most for telemedicine consultations with their regular veterinarian and least for a consultation with a veterinarian outside their community.

While this paper reports on research in the US and only involved hypothetical transactions, it does suggest that pet owners value the relationship they have with their regular veterinarian more highly, even when seeking online advice.

Bishop, G.T. et al. (2018) Owner satisfaction with use of videoconferencing for recheck examinations following routine surgical sterilization in dogs. Journal of the American Veterinary Medical Association 253 (9), pp. 1151-1157. https://doi.org/10.2460/javma.253.9.1151

This paper reports on a small randomised trial comparing owner satisfaction with post-operative recheck consultations carried out either remotely (telemedicine group) or in the veterinary clinic (control group). All the dogs had undergone uncomplicated neutering and the owners had to agree to random allocation and to complete an online survey. Although 37 dogs were initially enrolled in the study seven owners later dropped out for a variety of reasons This left a study population of 30 dogs.

The study found that owners were equally satisfied with recheck examinations performed by videoconference and in-clinic appointments. Owners of dogs in the telemedicine group indicated that their dogs were less afraid during the virtual appointment, compared with what was typical for them during in-clinic appointments, but the difference was not statistically significant. Most owners who completed a postsurgical recheck examination by videoconferencing preferred this method for similar appointments in the future. The study did not collect any information on veterinarian satisfaction with the two methods of examination.

This study suggests that while in clinic consultations will continue to be necessary for a range of reasons, including the condition of the animal and owner preference, those owners who have experienced remote consultations may prefer this method for similar consultations in future.

Using technology and apps to augment the consultation

Vezzosi, T. et al. (2019) Home monitoring of heart rate and heart rhythm with a smartphone-based ECG in dogs. Veterinary Record, 184(3) pp 96-96. https://dx.doi.org/10.1136/vr.104917

This paper reports on a small study to assess the feasibility of the home monitoring of heart rate and rhythm in dogs using ECG tracings recorded by owners with a smartphone ECG device (AliveCor Veterinary Heart Monitor along with its software interface AliveECG Vet). Following cardiac evaluation 33 dogs were recruited to the study. Their owners were asked to record serial ECG recordings at home and complete a short questionnaire to assess satisfaction and ease of use of the smartphone ECG device.

Thirty-one owners (94 %) felt that the recording technique was easy to learn and that the smartphone ECG device was easy to use. Fifteen owners (45 %) required a second person to hold the dog during recording. Of the 150 smartphone ECG tracings that were received, 134 (89 %) were interpretable.

This paper was reviewed for InFocus December 2018 which concluded that dog owners found using a smartphone ECG device relatively easy and that the quality of ECG tracings produced was acceptable for interpretation. This suggests that the device may be useful as an additional tool for frequent home monitoring of heart rate and heart rhythm in dogs

While this study does demonstrate the feasibility of owners making ECG recordings at home it does require access to appropriate technology and an initial surgery visit for more detailed cardiac assessment for the animal and training in use of the device for the owner.

Papers assessing the use of smartphone recording of ECG in other species

Vezzosi, T. et al. (2018) Evaluation of a smartphone electrocardiograph in healthy horses: comparison with standard base-apex electrocardiography. Journal of Equine Veterinary Science, 67, pp. 61-65. https://doi.org/10.1016/j.jevs.2018.03.006

Bonelli, F. et al. (2019) Comparison of smartphone‐based and standard base‐apex electrocardiography in healthy dairy cows. Journal of Veterinary Internal Medicine, 33 (2), pp. 981-986. https://doi.org/10.1111/jvim.15396

Smith, J.S. et al. (2020) Comparison of standard electrocardiography and smartphone-based electrocardiography recorded at two different anatomic locations in healthy meat and dairy breed does. Frontiers in Veterinary Science, 7, p. 416. https://doi.org/10.3389/fvets.2020.00416

It is important to be aware that not all smartphone apps made available to pet owners provide reliable data.

Evaluation of a home urinalysis kit in dogs

Krimer, P.M. Tanner, M.C. and Camus, M.S. (2019) Evaluation of a home urinalysis kit in dogs. Journal of the American Animal Hospital Association, 55 (3), pp.144-151. https://doi.org/10.5326/JAAHA-MS-6881

This paper reports on the accuracy of a commercial at-home urinalysis kit using a smartphone app to evaluate free-catch urine, which is marketed directly to dog and cat owners. The aim of the study was to assess agreement between the at-home analysis kit and the standard methods used in the Teaching Hospital’s laboratory (dry reagent dipstick urinalysis, refractometry and microscopy) based on 48 canine urine samples.

All urine samples were tested by standard dry reagent dipstick and refractometry within 30 minutes of arrival at the laboratory. The urine was then stored at room temperature for up to 6 and then retested by dry reagent strip, home urinalysis kit and specific gravity, using a portable refractometer. Sediment was also examined by microscopy.

The commercial kit had at least one clinically significant disagreement with the reference method per sample, with 77% having three or more differences. Specific gravity and pH concurred with the reference method in only 31% (P<.011) and 27% (P<.001) of cases, respectively. The sensitivity was low for all analyses except ketones, which had 77% false positives. False-positive nitrites and leukocytes were also frequent (36 and 19%, respectively). False negatives for blood (27%), nitrites (38%), and protein (54%) were common.

The authors note that dry reagent strips are a relatively inexpensive test for urine screening, but that urine should ideally be analysed within 30 minutes of collection (two hours if refrigerated). They also note that dry reagent pads from dipsticks for specific gravity, nitrites and leukocytes are not considered reliable in veterinary species.

Despite the limitations of this study, including a single unblinded researcher, delays in analysing urine samples, and the inclusion of results from the commercial test kits with reversed test strips, this paper does highlight the need to be cautious about interpretation of results from home kits, which may provide inaccurate results.

Other references

Stygar A. H. et al. (2021) A systematic review on commercially available and validated sensor technologies for welfare assessment of dairy cattle. Frontiers in Veterinary Science, 9, no. 177. https://doi.org/10.3389/fvets.2021.634338

Using images to augment the consultation

The papers below demonstrate possible uses of images to aid remote consultations, where direct examination of the animal is not possible.

Watanabe, R. et al. (2020) Inter-rater reliability of the Feline Grimace Scale in Cats undergoing dental extractions. Frontiers in Veterinary Science, 7, p.302. https://doi.org/10.3389/fvets.2020.00302

This paper reports on a small prospective blinded study of 24 cats, which had undergone dental extractions. The aims of this study were to evaluate the inter-rater reliability of the Feline Grimace Scale (FGS) after oral treatment and the effect of the caregiver’s presence on FGS scores

Images of the cats’ faces were captured from video recordings with or without the caregiver’s presence at six hours postoperatively (day 1), day 6, and before and after any rescue analgesia. The images where then randomized and independently evaluated by four raters using the FGS. A total of 91 images were scored (0-2) on 5 criteria: ear position, orbital tightening, muzzle tension, whiskers, and head position.

These were compared against real-time pain assessment performed by one male observer using the Glasgow Composite Measure Pain Scale-Feline (CMPS-F) at 23 different time-points from day 0 to 6. This observer was unaware of the oral condition and/or treatment of the cat. Additionally, there were 29 images with a corresponding match (i.e. image from the same time-point with or without caregiver’s presence), resulting in 58 images to be reviewed

The authors reported that FGS scores showed good inter-rater reliability [0.84 (0.77–0.89)], although the reliability for muzzle [0.56 (0.43–0.690)] and whiskers [0.64 (0.50–0.76) were lower than for ears [0.68 (0.55–0.78)], orbital tightening [0.76 (0.65–0.84)], and head position [0.74 (0.63–0.82)]. The FGS scores were not different with [0.075 (0–0.325)] or without [0.088 (0–0.525)] the caregivers’ presence (p = 0.12).

Despite acknowledging the limitations of the study (small sample size, poor image quality in some cases and under representation of cats with high pain scores on CMPS-F) the authors concluded that the FGS is a reliable tool for assessment of oral pain in cats, though some action units were difficult to identify due to poor image quality and facial oedema and inflammation. The caregiver’s presence did not affect the FGS scores.

While the data for this study was collected in a veterinary clinic, it does raise the possibility of using video recordings made by owners to aid in the assessment of post-operative pain, in cases where it may be difficult to see the cat in the surgery.

Gant, P. et al (2016) Can you estimate body composition in dogs from photographs? BMC Veterinary Research, 12 (1), 18. https://doi.org/10.1186/s12917-016-0642-7

In this retrospective study, photographs taken before and after weight loss from 155 overweight and obese dogs were examined by observers with a range of experience who estimate body condition indirectly using three different methods. The images used standard views (lateral and dorsal) to enable abdominal and thoracic width to be assessed or measured. The authors concluded that an estimate of body condition can be obtained from an indirect assessment of photographs, but performance varies amongst observers.

Whilst not perfect, this does suggest that such a measurement produces a broad guide to body condition, which might be useful clinically.

Packer R.M.A. et al (2015) Inter-observer agreement of canine and feline paroxysmal event semiology and classification by veterinary neurology specialists and non-specialists. BMC Veterinary Research, 11 (1), 39. https://doi.org/10.1186/s12917-015-0356-2

The aim of this study was to investigate the level of agreement between vets (both neurology specialists and non-specialists) on the description and classification of videos depicting paroxysmal events, without knowing any results of diagnostic workup. Participants watched 100 videos of dogs and cats exhibiting paroxysmal events and answered questions regarding: epileptic seizure presence (yes/no), seizure type, consciousness status, and the presence of motor, autonomic and neuro-behavioural signs.

On average there was only 29% agreement between observers as to whether a video represented a seizure event or not, This suggests that in isolation, observing videos of paroxysmal events may be an unreliable way to diagnose a seizure, thus highlighting the importance of detailed history taking, physical examination and diagnostic testing in determining whether an epileptic seizure has occurred.

Using structured data collection to augment the consultation

For those who do not have access to the technology the following papers report on the use of structured methods of data collection which may help to provide more objective information where the animal cannot be directly examined.

Porciello, F. et al. (2016) Sleeping and resting respiratory rates in dogs and cats with medically-controlled left-sided congestive heart failure. The Veterinary Journal, 207, pp. 164-168. https://doi.org/10.1016/j.tvjl.2015.08.017

This paper reports on a multicentre prospective observational study in which owners of 51 dogs and 22 cats were asked to count the sleeping (SRR) and resting respiratory rate (RRR) of their animal on 8-10 occasions over at least four days. All the animals had been diagnosed with left-sided congestive heart failure (CHF), and were on treatment at the time. While the majority of the animals had no co-morbidities, those that did, including large airway disease, osteoarthritis and endocrine disease, were not excluded from the study. However, dogs with primary respiratory disorders, such as acute pneumonia; primary pulmonary vascular disorders, such as pulmonary thromboembolism; severe heartworm disease, or severe metabolic derangements such as heat stroke, were excluded.

In dogs the median SRR was 20 breaths/min (range 7–39 breaths/min); eight dogs were ≥25 breaths/min and one dog only was ≥30 breaths/min. In cats the median SRR was 20 breaths/min (range 13–31 breaths/min); four cats were ≥25 breaths/ min and only one cat was ≥30 breaths/min. In both species SRR remained stable during collection with little day-to-day variability

In both species the RRR was slightly higher with the median canine RRR of 24 breaths/min (12–44 breaths/min), and the median feline RRR of 24 breaths/min (15–45 breaths/min).

The authors conclude that most dogs and cats with stable, medically controlled CHF have SRR <30 breaths/min and relatively small day-to-day changes in SRR in the home environment.

This may provide a relatively simple way for straightforward way for clients to monitor animals at home and provide additional information about whether animals need further assessment or changes to medication.

Enomoto, M., Lascelles, B.D.X. and Gruen, M.E. (2020) Development of a checklist for the detection of degenerative joint disease-associated pain in cats. Journal of Feline Medicine and Surgery, p.1098612X20907424. https://doi.org/10.1177/1098612X20907424

A journal watch summary of this article is available.

The aim of this study was to develop a checklist, with adequate accuracy that could be completed by owners and used to identify cats likely to have pain associated with degenerative joint diseases (DJD). Based on the data it was found that the six questions would identify 99% of cats with clinically confirmed DJD and had a specificity of 100%.

It was acknowledged that the proposed checklist has limitations, including that two of the six questions are about stairs which will not be applicable to all owners’ home setting, and the fact that the checklist has not been evaluated in cats with other diseases.

The review concluded that the proposed Feline Musculoskeletal Pain Screening Checklist offers an easy to use tool that may help veterinary surgeons screen cats for potential signs of DJD and engage owners in the monitoring of DJD associated pain behaviours in their cats.

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