Article Text

Download PDFPDF

Conference report
Building a veterinary evidence manifesto

Abstract

Ingrid Torjesen reports from EBMLive, where Vet Record ran a workshop session to explore what vets can learn from the human medical world when it comes to driving evidence-based practice.

View Full Text

Statistics from Altmetric.com

Workshop panel (left to right): Lysan Eppink, Sally Everitt, Daniella Dos Santos, Suzanne Jarvis, Rachel Dean, Marnie Brennan

Evidence-based veterinary medicine is about good clinicians using good science to make good decisions about their patients to benefit their health and welfare.1 That is the definition from the Centre for Evidence-based Veterinary Medicine. And in order to achieve this the veterinary profession needs high quality, relevant science made readily available to them in clinical practice.

Progress in this area was explored at the recent EBMLive, an annual conference organised by The BMJ and the University of Oxford’s Centre for Evidence-based Medicine. Over the years, the conference, which seeks to ‘develop, disseminate and implement better evidence for better healthcare’, has highlighted that available evidence is often of poor quality, questionable integrity and does not answer the research questions that matter in human medicine.2

Two years ago, in order to address this, The BMJ and the Centre for Evidence-based Medicine attempted to set out the steps required to develop a trustworthy evidence base in human health. This was refined through a series of activities with stakeholders, including seminars, roundtable discussions, online consultations, and direct feedback, culminating in the evidence-based medicine (EBM) manifesto (see Box 1).3 This manifesto exists to improve the relevance of research to patients and reduce research wastage and bias.

Box 1:

Evidence-based medicine manifesto for better health

  • Expand the role of patients, health professionals, and policy makers in research

  • Increase the systematic use of existing evidence

  • Make research evidence relevant, replicable, and accessible to end users

  • Reduce questionable research practices, bias, and conflicts of interests

  • Ensure drug and device regulation is robust, transparent, and independent

  • Produce better usable clinical guidelines

  • Support innovation, quality improvement, and safety through the better use of real world data

  • Educate professionals, policy makers, and the public in evidence-based healthcare to make an informed choice

  • Encourage the next generation of leaders in evidence-based medicine

Developing a veterinary manifesto

This year, for the first time at EBMLive (held in Oxford, UK), the conference programme had a dedicated session to examine evidence-based medicine in the veterinary sector. A six-strong panel led a discussion with stakeholders in the audience to pinpoint the key issues that need addressing in the sector and how these compared with those identified in human medicine. Together they adapted the EBM manifesto to produce a draft one for veterinary medicine (see Box 2).

Box 2: Draft evidence-based veterinary manifesto as adapted from the human model (see Box 1)

The veterinary manifesto needn’t be a particularly strong departure from its equivalent in human healthcare but, obviously, it includes the added component of a client customer – the farmers and owners of the animals.

Rachel Dean, a founding director of the Centre for Evidence-based Veterinary Medicine at the University of Nottingham, told the meeting: ‘We often say we need good science and good professionals to make decent decisions and, to me, what the manifesto is about is how we actually go about making this a reality rather than just a theoretical concept.

A lot of other people are responsible for research, including funders, journals, reviewers and readers

‘To get best relevant evidence we need good science, and a lot of the time that is thrown at the feet of just the researchers,’ said Dean, whose day job is now director of clinical research and excellence in practice at VetPartners. But a lot of other people are responsible for research, including funders, journals, reviewers and readers, she said.

There’s obviously more work to do on improving the quality of research, and critiquing the evidence, she argued, but she sees an opportunity to make a difference at the point of decision making, taking into account client/patient values and circumstances. ‘Up until that point we are reading papers and thinking about them and chatting about them, but it’s not until we make a decision and act that we actually implement any kind of effect on care.’

And for good decision making, we need good professionals, Dean emphasised, and that is affected by their place of work, its culture, their education, professional development and support, professional regulation, and relationships with colleagues, the rest of the clinical team and the animals’ owners/carers.

Suzanne Jarvis, managing editor of Vet Record, agreed that the EBM manifesto looked like it would fit a veterinary manifesto well, but with one very important caveat. The needs and wishes of patients and clients might not always be the same in veterinary medicine, so it was important to recognise the patient – and animal welfare – as separate to the client in the manifesto.

Integrating evidence into practice

Sally Everitt, an independent small animal practitioner and a member of the BVA policy committee, said published evidence was not really being integrated with clinical expertise, patient circumstances or client values. There were two main reasons for this – not enough time and not the right evidence.

‘[Practitioners] say we don’t have time to find and appraise literature,’ she said. ‘Partly they say there’s too much to keep up with, partly they say there’s not enough evidence for what we want to do, and this probably comes down to the fact that we don’t perhaps have the right evidence to be making the decisions that we need to in practice.’

Dean agreed, saying there was a perception that evidence-based medicine required the ‘holy grail’ of randomised controlled trials and systematic reviews. But these approaches had a deficit – she argued, they didn’t encompass shared decision making. ‘We make decisions every day, so we need to work realistically with what we’ve got.’

Everitt pointed out that the cases reported in trials were rarely representative of what practitioners saw in everyday practice. ‘We have an ageing population with lots of comorbidities which are immediately excluded from all the clinical trials.’

Marnie Brennan, deputy director of the Centre for Evidence-based Veterinary Medicine, University of Nottingham, said the clinical research that would be most useful in everyday practice was not attractive to funding bodies or to interns and residents undertaking research projects as part of their training. As a consequence, it rarely found its way into high-impact journals.

Unfortunately, most research is carried out at the third tier referral sector rather than in primary and charity practice, said Runa Hanaghan, deputy veterinary director at the Dogs Trust.

Journals such as Vet Record would welcome the opportunity to publish more first-opinion-type papers, said Jarvis, but they just weren’t submitted. ‘We do commentary pieces, key points, and so on to help people see how the [available] research is relevant to them.’

Duncan Jarvies, multimedia editor at The BMJ, pointed out that in human medicine 85 per cent of research spending is wasted, primarily because the research question has already been answered.

When you’re in practice those negative results are really important, so you know what not to do

In addition, it is mostly positive rather than negative results that are published and shared, said Daniella Dos Santos, junior vice president of the BVA. ‘When you’re in practice those negative results are really important, so you know what not to do.’

The meeting discussed how a lack of independent funding streams in veterinary medicine meant a lot of research was funded by drug companies. This raised difficulties around conflicts of interest, said Brennan.

Understandably, drug companies presented their registration trial data in the best way possible to make their product stand out from its competitors, said Lysan Eppink, a technical adviser in pig products at Boehringer Ingelheim and senior vice president of the British Cattle Veterinary Association. This meant it was important for practitioners to have good training in applied statistics so they could interrogate findings, she said.

First-opinion practitioners who have been out of academia for many years needed to be given the confidence and support to be able to undertake evidence-based research, Dos Santos said, adding that it was also important to think about how they were compensated for doing so.

Tim Potter, clinical director at Westpoint Farm Vets, said it is not just about compensating for the time involved, it was also about ensuring vets had the required skill base for conducting research and assessing evidence.

‘We have always actively encouraged our younger vets to get involved with research,’ he said, ‘it’s actually [about] having the infrastructure there to push it forward.’

Dean said one of the advantages of corporatisation was that you could build very good clinical teams and the potential to influence and make a change is on a larger scale. ‘[One way] corporates in particular can help is increasing the role of people participating in research’, she said. ‘At VetPartners, we want clinical excellence work to be part of the everyday job and that includes getting involved in clinical research in some shape or form.’

However, she added that success relied on having a good IT infrastructure to make the most of the data available.

Brennan said it was important to up-skill people in how to evaluate research so that if they had the time and inclination to engage with building the evidence base, they already had the skills. But it was also important to have regular appraisals of the evidence available, such as knowledge summaries, BestBETS for Vets and better guidelines, for those that didn’t.

Those in the audience for the workshop also contributed to the debate on the EBM manifesto and whether it was fit for a veterinary purpose

‘I don’t particularly like a lot of the guidelines that exist at the moment because of the way they’re developed, and their applicability to the real world. They don’t tend to help decision making generally,’ she said.

Everitt said ‘We need evidence available at the point of care, we need guidelines. We need to know how to appraise and value clinical expertise as well as published evidence, we need to get better at discussing uncertainty and risk, and we need to bring animal owners into discussion at an early stage.’

One of the things that is ‘noticeably absent’ in the development of guidelines is the involvement of clients, Chris Gush, executive director of RCVS Knowledge, pointed out. This meant that services tended to be designed to suit the person who’s delivering it rather than the people that are receiving it’.

Involving all stakeholders in the creation of guidelines made them more usable and potentially more effective, Dean agreed.

Making the language relevant

There are practitioners out there practising evidence-based medicine every day without realising it

Evidence-based medicine was often looked at from a narrow academic perspective, ‘and yet there are practitioners out there practising evidence-based medicine every day without realising it – your clinical rounds, your audits, your governance,’ she said

The panel

  • Marnie Brennan – deputy director of the Centre for Evidence-based Veterinary Medicine, University of Nottingham

  • Rachel Dean – director of clinical research and excellence in practice at VetPartners

  • Daniella Dos Santos – junior vice president of the BVA and a small animal practitioner

  • Lysan Eppink – technical adviser in pig products at Boehringer Ingelheim and senior vice president of the British Cattle Veterinary Association

  • Sally Everitt – independent small animal practitioner and a member of the BVA policy committee

  • Suzanne Jarvis – managing editor of the BVA veterinary titles, including Vet Record and In Practice

‘The lack of relevance or perceived value’ of evidence-based medicine suggested that the profession needed to look at the language used and make it more relevant and accessible to the general practitioner.

Younger vets in particular are often keen to practise it, Dos Santos emphasised, but they may lack the confidence to do so and they needed to be ‘empowered’ to have conversations with their seniors.

Another barrier, Brennan said, was that training in evidence-based medicine tended to be quite dry and early on in the veterinary course, whereas it really needed to be taught at the end of the course in the context of point of care.

Then, it needs to be ‘grandfathered into practice’, she added. ‘If they see people doing it they’re more likely to do it themselves.’

In human medicine, there is robust post marketing surveillance and death certificates, so if a patient shows serious adverse effects or dies there will be an investigation, said Roger Ede, a former microbiologist. ‘Presumably the only way you know [a patient has] gone is because the client owner stops coming?’ he asked.

‘Monitoring the outcomes of treatment is something that, to date, we’ve not been particularly good at,’ Dos Santos admitted. ‘We don’t have death certificates, we also have euthanasia, so survival is a complex thing.’ And as only a third of cats and dogs actually visit the vets, practitioners know little about outcomes in the remainder.

Everitt pointed out that there is a reporting system for adverse reactions to medicines through the Veterinary Medicines Directorate, and professional indemnity insurers also had a very new forum for reporting near misses called VetSafe. Also the Small Animal Veterinary Surveillance Network (SAVSNET), among others, monitored disease trends over time as well as treatments and outcomes.

‘I think what this is highlighting,’ Dos Santos added, ‘is perhaps the structural differences between human medicine and veterinary medicine mean there is less communication and knowledge sharing between individual [vet] practices.’

There is also more unlicensed use of drugs, as they are not tested in all species, and adverse reactions from unlicensed use often went unreported, she said.

‘Unfortunately, that’s not done very often unless things go very wrong,’ Eppink said, adding that drug companies were very keen to collect information on positive as well as negative outcomes from off-label use, because the information might highlight some benefits that can be investigated.

Communication and sharing

Gush said there was a view among vets that the NHS was this huge organisation that communicates very well, but in reality it was ‘almost as fragmented as the veterinary world’. However, he said, there was an appetite to share learning that was not present in the veterinary world. ‘That’s a cultural challenge that maybe corporatisation was going to help improve,’ he said.

‘In this unstable environment that we have within our profession at the moment it’s very tricky to create infrastructure and connectivity,’ Dean said. ‘But in four years’ time, it will have stabilised out. It’s an opportunity we don’t have when we are three and a half thousand small practices [but we do when] we actually become four big businesses.’

Like the EBM manifesto in human medicine, Dean concluded that a manifesto for veterinary medicine needed to encompass principles such as increasing the diversity of stakeholders in research, increasing the use of evidence in practice and making evidence applicable in practice. Other important aspirations were reducing questionable research practices and conflicts of interest, regulating drugs better and start regulating veterinary devices, creating better guidelines, keeping language straightforward and encouraging the next generation of leaders in evidence-based medicine.

But, in addition, at the very top it needs to highlight that animal welfare is the priority, she said.

Next steps

Vet Record would like to publish a final evidence-based veterinary medicine manifesto in 2020. We welcome feedback from the profession. If you have any comments or suggestions on the draft manifesto please contact us at vet.editorial{at}bmj.com

References

View Abstract

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles