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Survival time of dogs with congestive heart failure & the effect on revenue | VETgirl Veterinary Continuing Education Podcasts

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In today’s VETgirl online veterinary continuing education podcast, we review the survival time of dogs with congestive heart failure… but add a unique twist to this… the effect of revenue. This sounds strange, but keep listening.

As human perception of companion animals has evolved, the demand for specialty and 24-hour emergency veterinary care has likewise increased. In theory, specialized medicine (human or veterinary) should improve diagnostic accuracy and patient care but evidence to support this idea is lacking in veterinary medicine. Collaborative care between general physicians and cardiologists in the human realm is known to improve patient outcome (compared with care by a general physician, alone) based on published data. Limited investigation of the effect that collaboration by primary care veterinarians and veterinary cardiologists has on patient care exists, and the additional question of whether this collaboration would have a negative impact on primary care veterinarian revenue is lacking in investigation, as well.

In other words, are primary veterinarians referring less to veterinary specialists as they are concerned about specialists taking away from their potential long term revenue?

So, Lefbom et al out of the CVCA-Cardiac Care for Pets in Leesburg, Virginia wanted to evaluate this in a study called “Impact of collaborative care on survival time for dogs with congestive heart failure and revenue for attending primary care veterinarians.” The purposes of this study were to evaluate 1) the effect of collaborative, in-person care by primary care veterinarians (pcDVMs) and board-certified veterinary cardiologists (BCVCs) on patient outcome in dogs with CHF secondary to myxomatous mitral valve degeneration (MMVD) (compared with pcDVM care alone) and 2) the effect of this collaboration on pcDVM revenue.

This was a retrospective cohort study that reviewed 26 small-breed dogs that were > 9 years old and < 15 kg body weight that were diagnosed with congestive heart failure (CHF) in the medical records between 2008-2013; the diagnosis with confirmed retrospectively by the BCVC investigator of this study. Inclusion criteria for this study included the recorded date of death or euthanasia secondary to cardiac disease, clinical signs of CHF (e.g., such as cough, tachypnea), systolic mitral valve murmur IV/VI or louder, and a VHS of > 11.0 (on radiographs) or an LA:Ao ratio of > 2.0 (on echocardiogram) w/clear evidence of mitral valve degeneration and regurgitation on echocardiogram. Exclusion criteria for this study were a survival of less than 7 days after onset of CHF, concurrent disease (like concurrent lower airway disease, chronic cough, neoplasia, etc.), and having a systemic disease that required treatment. When assessing revenue, the revenue data was normalized to 2013 using the US Bureau of Labor Statistics consumer price index inflation calculator. As for collaborative care with a BCVC, it was defined as a referral to a BCVC for direct examination within 1 month of diagnosis of CHF and a relationship with a BCVC that was maintained until death of the patient (≥ in person recheck with pcDCM or BCVC and direct communication between pcDVM and BCVC as well as with owner).

So, in this study, a total of 26 dogs were included, of which 18 received collaborative care between the pcDVMs and BCVC. 8 were managed by the pcDVM care alone. What did the authors find? There was no difference between these two groups with respect to age, body weight, breed, or sex. There was a statistically significant difference in median survival time from onset of CHF to death between the two groups; in dogs receiving collaborative care between pcDVMs and BCVC, the average survival was 254 days (range: 160-483 days, 95% CI) compared to 146 days (range: 73-263 days, 95% CI) in those managed by the pcDVMs alone (P = 0.045 initially, P = 0.012 after adjusting for age/body weight). As for the effect on revenue? There was no significant difference in the pcDVM revenue between these two groups (P = 0.45), but a significant positive correlation (P < 0.001) between survival time and pcDVM revenue for dogs receiving collaborative care. In other words, the longer the dog survived, the greater the revenue that was generated by the pcDVM from caring for the patient.

This study showed that dogs receiving collaborative care for CHF (secondary to MMVD) between a pcDVM and BCVC resulted in 74% longer survival, similar to findings reported in human medicine. The median survival times for the population (CHF/MMVD) were similar to prior studies, further strengthening the study data’s credibility. Although a 22% increase in pcDVM revenue was identified with collaborative care, this was not statistically significant. The authors believe this is due to the study’s low power associated with the small study population (26 dogs), however. What was significant, however, was the correlation between pcDVM revenue and survival time with collaborative care.

What are the limitations from this study? The small study population was the primary limitation of the study, not only in terms of statistical power, but in terms of potential for significant error due to the wide range of variability in assessing owner interest in referral to BCVCs, consistency of pcDVM recommendation of referral to BCVCs, and the variability in pcDVM medical records.

What do we take from this VETgirl podcast?

While this was a more “unusual” type of study, it’s the first of its kind in veterinary medicine to tackle a somewhat uncomfortable issue in a profession that ultimately is a form of private enterprise, regardless of all of our best medical intentions. There is likely little debate among general veterinarians that referral to a specialist should provide improved evaluation and care for a pet, with the prospect therefore of improved survival and/or quality of life. But the real concerns about revenue competition (and ultimately revenue loss) expressed by primary care veterinarians in a 2006-07 forum by the American Animal Hospital Association do not appear to be supported by the results of this small retrospective study (and rather suggest that the opposite may be true). This study may serve as a first step in alleviating some of the financial pressures felt by some pcDVMs that have historically hindered referral to specialists, and ultimately begin to improve, rather than impede, the collaboration between pcDVMs and board certified veterinary specialists.

Most importantly? Collaboration between pcDVMs and BCVCs improved survival time for dogs with CHF/MMVD, had no demonstrable negative impact on pcDVM revenue, and furthermore demonstrated a clear positive correlation between pcDVM revenue and survival time with collaborative care that was not observed with pcDVM care alone. So please, don’t be scared to refer to us veterinary specialists. Because we can potentially help your patients live longer too!

References:
Lefbom BK, Peckens NK. Impact of collaborative care on survival time for dogs with congestive heart failure and revenue for attending primary care veterinarians. J Am Vet Med Assoc 2016;249(1):72-76.

Abbreviations:
pcDVM: Primary care veterinarian
BCVC: Board certified veterinary cardiologists
CHF: Congestive heart failure
MMVD: Myxomatous mitral valve degeneration
Kg: kilograms
VHS: Vertebral heart scale
LA:Ao: Left atrial to aortic root ratio
95% CI: 95% confidence interval

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