Recasting the gold standard – part I of II: delineating healthcare options across a continuum of care

Abstract

Aim

This is the first part of a two-part series on spectrum of care that encourages practitioners to embrace a non-binary approach to healthcare delivery. When care is not framed as all-or-none, either/or or best versus lesser, the provider and client can agree to diagnostic and/or treatment plans that individualize the practice of veterinary medicine. Care is tailored to the patient along a continuum of acceptable options. Care may also be intentionally incremental, with plans to reassess the patient and revise case management as needed.

Relevance

Acknowledgment and ultimately acceptance that patient care journeys can be distinct, yet equitably appropriate, offers providers the flexibility to adapt case management competently and confidently to the patient based upon contextualized circumstances including client needs, wants and expectations for healthcare outcomes. Thinking outside the box to recast the historic gold standard with a continuum of care strategically offers feline practitioners a means by which they can overcome barriers to healthcare delivery.

Series outline

This first article introduces spectrum of care as an appropriate approach to case management and broadens its definition beyond cost of care. Part II explores communication strategies that enhance veterinary professionals’ delivery of spectrum of care through open exchange of relationship-centered dialogue.

Keywords

Spectrum of care continuum of care relationship-centered care access to care accessibility of care cost of care healthcare barriers

Introduction

Advances in the delivery of veterinary healthcare over the past several decades have exponentially enhanced our diagnostic and therapeutic capabilities in the realm of both medicine and surgery.^1–3 Innovative technologies, including wearable devices, have revolutionized our ability to monitor and track patient health in non-clinical environments.^4–6 Ultrasonography^7–12 dental radiography,^13–16 echocardiography,^17–20 fluoroscopy,^21–24 CT^25–27 and MRI^25,28,29 are becoming routine offerings by general practices and/or referral facilities, and three-dimensional printing can now be applied at tertiary institutions as a means of preoperative planning.^30,31

Advances in veterinary healthcare delivery also stem from an internal desire to deepen content area expertise through specialization. A total of 22 veterinary specialty organizations are currently recognized by the American Veterinary Medical Association (AVMA), comprising 46 distinct specialties,³² and there is growing interest within the profession to explore the impact of complementary and alternative veterinary medicine on patient outcomes.^33,34

Despite these advances that drive medicine forward, there is a growing veterinary health gap.^35,36 The divide between those who can afford veterinary care and those who cannot is apparent.^35,37–40 The economic recession of 2007–2009 widened the gap and amplified concerns about the affordability of veterinary care.⁴¹ Of those who participated in the Bayer veterinary care usage study, unemployed cat owners and those earning less than US$35,000 per year were less likely to have taken their cat to the veterinarian than dog owners with the same employment or income status.⁴¹ Rising costs of veterinary services were named as a primary reason for not seeking care, and cat owners were more likely to forgo wellness examinations than dog owners.⁴¹ Of participating cat owners, 40% had not presented their cat to a veterinarian within the 12 months before the survey, compared with 15% of dog owners.⁴¹ It is noteworthy that this statistic reflects care only for owned cats, not the large number of unowned free-roaming community cats that also need care and that also often have caregivers who lack access to veterinary care.

The cost of care is particularly impactful for low-income and underserved communities and may be pricing people out of pet ownership.^39,42 A 2015 study by the American Society for the Prevention of Cruelty to Animals (ASPCA) disclosed that over one million households rehome or surrender their pets each year.⁴³ Of respondents, 46% identified a pet-specific reason for rehoming or relinquishment.⁴³ Of these, roughly one-quarter named their inability to afford costs associated with care as the primary reason.⁴³ Statistics such as these have given rise to a lively debate within the veterinary profession about whether ‘having a pet is a privilege and not a right’ and ‘if you can’t afford a pet, you shouldn’t have one’.^44,45 Yet, the evidence shows that individuals with limited means, including those facing housing insecurity, routinely prioritize their pets’ health over their own.^44,46–49

Companion animals are considered to be family by 85–99% of pet owners.^50–54 Many anthropomorphize their pets and attribute love as the foundation of their bond.⁵⁵ This distinction emphasizes the value that is placed upon pet ‘ownership’. Many see themselves as pet parents or guardians.^56,57 Within the family structure, pets may be seen as siblings to human children, prompting some owners to consider themselves as pet parents.^58–64

The price of companionship

Veterinarians agree with clients that the rising and often unexpected costs of care frequently limit the types of diagnostic and therapeutic interventions that can be pursued.^{39,40,42,65–67} From the veterinary perspective, cost alone may determine veterinary care decisions for some or even prevent pet owners from seeking veterinary care.^40,41,67 In a 2017 cross-sectional study by Kipperman et al, 57% of surveyed veterinarians acknowledged that economic constraints restrict their ability to deliver healthcare.⁴⁰ Limitations in clients’ capacity to afford care and veterinary barriers to financing care contribute to burnout within the veterinary team and secondary traumatic stress for veterinarians and pet owners alike,^40,68–71 particularly in cases of economic euthanasia.^72–75

Many pet owners enter consultations expecting veterinarians to initiate conversations about anticipated healthcare costs.⁶⁵ Pet-owning participants in a 2007 focus group study by Coe et al shared the need for transparency with respect to costs of care and that these costs should be discussed upfront regardless of whether clients are new to the practice or established and know from past experience what to expect.⁶⁵ Despite their respective needs to engage in dialogue about cost, pet-owning participants shared that these conversations with veterinary teams were infrequent.⁶⁵ From the perspective of the clients, failure to discuss costs upfront makes it more likely for them to overextend themselves financially.⁶⁵

Veterinarians who participated in the same 2007 focus group study by Coe et al agreed that avoidance of cost-based discussions is counterproductive to healthcare delivery and may contribute to clients’ mistrust.⁶⁵ Veterinary participants expressed that they at times struggle with assumptions and biases about what clients can afford. Prejudgments are especially problematic when cost is not perceived by the veterinarian to be an issue yet is, in fact, a significant constraint for the client.⁶⁵ Clients may experience so-called ‘sticker shock’ when pricing is not discussed upfront because costs are often higher than anticipated.^40,65,76

Despite the agreement between clients and veterinarians that cost-based conversations are essential to healthcare delivery, such discussions are uncommon in companion animal practice.^40,77 A 2017 study by Kipperman et al disclosed that conversations about financing care and pet insurance were initiated by only 31% and 23% of veterinarians, respectively.⁴⁰ Veterinarians cited lack of time as the primary reason for not discussing pricing, yet clients desire to engage in cost-of-care conversations.⁶⁵ A 2022 study by Groves et al confirmed that the prevalence of cost conversations remains low: cost was discussed between the veterinarian and client in 215/917 (23.4%) video-recorded appointments.⁷⁷ In 57/215 (26.5%) of these consultations, clients initiated conversations about cost.⁷⁷ Of the cost conversations, 31/215 (14.4%) explored how the service being offered would benefit the patient’s wellbeing.⁷⁷ These statistics indicate that cost conversations are often driven by clients rather than other members of the veterinary team and that few cost conversations highlight the value of diagnostic and/or therapeutic recommendations.

A 2018 report by the Access to Veterinary Care Coalition (AVCC) documented that 28% of surveyed pet owners had experienced a barrier to veterinary care in the past 2 years.³⁵ Nearly 1/4 (22.7%) of pet owners had been unable to provide preventive care to at least one pet.³⁵ Cost remains the primary barrier to healthcare.³⁵ Decreased visits to the veterinarian impact both patient and owner health. Patients without access to or with interruptions in preventive care may potentiate zoonotic disease, risking public health.^78,79

It is the veterinarian’s obligation to protect animals and public health.⁸⁰ Approaches to healthcare delivery that align with these duties are rarely all-or-none or either/or, but in fact stretch out along a continuum of acceptable and appropriate care options. Appropriate care has been defined by human healthcare professionals as that which is patient-oriented and evidence-based, in which anticipated health benefits exceed expected negative consequences.^81,82 For this practice to be sustainable, patients must be informed about the range of available, effective interventions so that they can determine which is most acceptable to them.⁸³ The philosophy of providing suitable options from which patients can choose, based upon contextualized circumstances, defines the practice of spectrum of care. To understand how to move forward in healthcare with this practice in mind, one must first acknowledge our past, what we as practitioners hold on to and why.

Mining for ore: the historic gold standard

The definition of optimal care has changed over the years within the practice of veterinary medicine.⁸⁴ Case management was historically dictated by the gold standard.⁸⁴ The term ‘gold standard’ originated as a currency exchange rate system.^84–87 Countries that subscribed to this system set a fixed price for gold and their currency was assigned a value relative to that price.^84–87 International trade was facilitated through exchange rates between countries that agreed upon the value of gold.⁸⁴

The term ‘gold standard’ first appeared in a human medical journal, The Lancet, in 1962. The commentary, ‘Towards a Gold Standard’, encouraged physicians to treat rheumatoid arthritis with gold salts.⁸⁴ The term did not take on its present-day meaning in human healthcare until 1979, when it appeared in an editorial by Dr Peter Rudd in Archives of Internal Medicine.^84,88 Frustrated by non-compliant patients, Rudd proposed that healthcare develop a gold standard for compliance to facilitate case management.^84,88 Between 1995 and 2005, the term has appeared in over 10,000 medical publications,⁸⁹ even though financiers gave up the idea of a gold standard decades ago.⁹⁰

Ironically, just as this antiquated system in economics was being put to rest, it took on new life within human healthcare ‘not merely as a standard of exchange but as the definitive exemplar of quality and reliability’.⁹⁰ Adrenal vein catheterization, cardiac catheterization and hemodialysis were coined gold standard procedures in human healthcare in 1980, 1981 and 1982, respectively.⁹⁰ By the 1990s, the gold standard had become synonymous with that which was considered ‘best practice’.⁹⁰

At the start, gold standard practice was a good-faith effort to improve healthcare quality in human medicine by basing clinical decisions on the best possible evidence. At an unknown point in time, gold standard practice trickled over from human healthcare and was adopted by the veterinary sector. Over time, gold standard practice evolved into medical monotheism, the belief that only one ideal approach to interventional medicine existed.⁷¹ Gold standard care implies that trailblazing technology and intensive or invasive interventions are, by default, the best options for case management.⁷¹ Yet the quest to find the perfect test or procedure is inherently flawed.⁹¹ Measures of diagnostic accuracy, such as sensitivity and specificity, help predict those with and without disease, but predictive ability is not omniscient. Interpretation of a human or veterinary patient’s health requires far more than comparing test results against reference intervals. A 2020 publication by Lester in Veterinary Clinics of North America: Small Animal Practice identified variables that must be considered when making determinations about whether a feline patient is healthy or sick.⁹² These variables include the lack of universal reference intervals, which vary between breeds and ages, sexes and geographical regions, as well as intraindividual and interindividual variation.⁹² Moreover, results are not interchangeable between sample types, machines and methodologies, making direct comparisons between methodologies inaccurate.⁹²

Where gold falls short

The perfect test does not exist; therefore, the gold standard can at most describe the best available test without restrictions at this moment in time. Yet, who defines what constitutes best practice – and when has medicine ever been static? Moreover, how can one approach to patient care be sufficient when considering the diversity of caseload and the uniqueness of each patient? Skipper et al acknowledged that:

‘Real-world contexts are infinitely variable. Constraints and affordances differ between primary and referral settings and by species of patient. Indeed, even within these categories, there are always differing animal factors (age, temperament, general health and environment) and human factors (resources, capabilities, preferences or circumstances of the owner, vet and veterinary clinic).’⁷¹

It is a disservice to patients to suggest that case management can adopt a one-size-fits-all approach. It is equally incorrect that any deviation from the current best practice is subpar. Alternatives to the gold standard are not by default an economy experience instead of first class. Yet, it is easy to cling tight to this ‘Plan A’ approach when it is the lens through which most veterinary students are introduced to clinical reasoning. We are trained to provide state-of-the-art medicine, which is often confused with standard of care. We are also trained to mitigate risk of litigation or disciplinary action by offering all diagnostic and therapeutic modalities rather than some.³⁷ For instance, the default work-up of a cat that presents with urinary tract obstruction⁹³ includes comprehensive bloodwork, urinalysis and diagnostic imaging.⁹⁴ Gold standard care dictates that the patient should be hospitalized after relieving the obstruction, to receive intravenous fluids and to monitor urine output via an indwelling urinary catheter.^84,94–98 Costs of care vary from clinic to clinic; however, in many hospitals, the cost of treating such a patient may easily approach, if not exceed, US$1000.⁹⁴ Clients who cannot afford such care may be offered euthanasia as a viable treatment option; however, the reality is that there are other approaches that span the divide between all or none.⁹⁴ Diagnostics could be scaled back, if performed at all, and hospitalization could be reduced.⁹⁴ Non-traditional outpatient management could also be pursued.^94,99

Rather than default to defensive medicine, we should ask ourselves the following questions:

What options are logical?

What options are appropriate for the patient, considering the patient’s temperament and fear-anxiety-stress level, comorbidities and the potential for adverse effects?

What options are appropriate for the client, factoring into consideration their abilities, beliefs, concerns, priorities and expectations concerning care?

What information will be gained from next step diagnostics or a therapeutic trial?

○ How will information gained alter our approach to case management?

○ How will information gained affect the patient’s outcome?

Answers to these questions are critical if we are to make patient-specific determinations about healthcare delivery. Answers to these questions also guide the process of shared decision-making as we help clients move beyond their initial preferences about case management to make informed choices.¹⁰⁰ Deliberation is the process by which our clients become aware that choices exist and what the impact is of those choices on client and patient alike. We owe it to our clients to engage in transparent dialogue about perceived and real risks versus benefits, and to solicit clients’ perspectives about what matters most to them moving forward.¹⁰⁰ Spectrum of care grants the freedom to bridge the gaps between an all-or-none approach to healthcare delivery and allows us to shift focus on to a wider array of options. Each option along the way is an opportunity for us to revisit our treatment philosophy:

What are we testing or treating for?

How do we make meaning of each test result or treatment outcome?

○ What do we know with certainty?

○ What remains unknown?

○ What is our comfort level with the unknown?

○ How do we bridge the gap?

Spectrum of care broadens the scope of the practitioner’s capacity to sift through combinations of treatments to find what is best for the patient and client in the context of their needs and abilities.¹⁰¹ Spectrum of care encourages practitioners to be adaptive and apply research evidence to the patients’ life context. Patients’ life context is critical because it connects us as practitioners to those on the other side of the consultation room table. It reminds us that our patients and clients are unique and that to drive care forward, we must better understand how they perceive a given situation, from the vantage point of their respective lenses.

Extracting what is more precious than gold: a continuum of choice

Relationships drive medicine forward because they establish and build upon trust.^102,103 Trust is made possible through perspective-taking and seeking, as well as displays of unconditional positive regard by the healthcare team.^102,103 When veterinary clients feel connected to providers, understood and validated, it is believed that they are more likely to adhere to treatment plans and comply with interventional care recommendations.^102–104 Compliance and adherence are also thought to improve when clients are given the opportunity to weigh in on how care is structured, delivered and received.^{103,105–107} As we invite clients to share their perspectives with us, we shift the consultation approach toward a dialogue in which choices are offered to clients, who may require time and other resources to deliberate.¹⁰⁰ The deliberation process may need to be staged and clients may require support as they formulate preferences for how to move forward with a decision.¹⁰⁰ Decision-making hinges on the clinician’s delivery and the client’s perceptions of pros and cons, the anticipated outcomes for and impact of each option.¹⁰⁰ The process is inherently collaborative, involving both client and veterinary professional as each considers key factors that influence decision-making. In the process, conversations between client and provider often blend several elements of care:

Pet-specific care

○ focuses on the patient’s needs, and the client’s needs, wants and expectations¹⁰⁸

Continuum of care

○ focuses on the range of options available to the healthcare team, which includes the client and patient³

Contextualized care

○ focuses on the ‘more flexible and inclusive acknowledgement that different treatment modalities may be equally valid in different contexts’ and that ‘we cannot separate clinical decisions from their social contexts’.⁷¹

Collectively, this trilogy gives rise to a spectrum of care in which acceptable care options can be tailored to meet the needs of a diverse patient population as well as diverse clientele. The local, state and national communities that veterinarians service are currently experiencing rapid states of growth. According to the Census Bureau, the population within the USA is expected to increase by 1.8 million people per year.¹⁰⁹ Within that population explosion, the USA is likely to see its population aged 65+ years double in size. In addition, the USA also faces a shift toward increasing populations of racial and ethnic groups. According to the US Census Bureau, roughly one out of every four people were non-white in 2004.^109,110 Projections predict that by the year 2050 one out of every two people will be non-white. This prediction suggests that those who are currently in the minority could become the majority within the next 25 years.¹⁰⁹ The rise in diversity of age, race and ethnicity within veterinary clientele is a vital reminder that clients are unique and require a tailored approach that elicits their perspective, and acknowledges and addresses their values, goals and expectations for care. Spectrum of care not only makes room for this diversity, it embraces diversity through the recognition that clients, patients and care options all span a continuum for which there is no carbon copy.

In addition to age, racial and ethnic diversity, socioeconomic considerations are also broadening in scope. Families in the USA that are enrolled in public assistance programs, such as food stamps, own an estimated 29 million dogs and cats and struggle to afford veterinary care.³⁵ Asset Limited, Income Constrained, Employed (ALICE) individuals are most acutely impacted by financial barriers.³⁶ They live paycheck to paycheck, and are challenged to finance high-cost, unexpected expenditures related to pet health.³⁵ Cost of care can be restrictive and affordability may be a significant barrier to gold standard healthcare practices. Financial constraints require the flexibility and integral care options that spectrum of care makes possible.

When one considers spectrum of care as an approach to the practice of veterinary medicine, cost is typically at the forefront in terms of whether the client can pay for services rendered. In practice, care plans are often formulated around cost, providing clients with options for high-end, middle-of-the-road and low-end care. However, it is never as simple as that. When we stretch our understanding of what it means to practice spectrum of care, we find ourselves widening the lens through which we manage clinical cases. We begin to consider not just cost but all the contextual elements that influence healthcare delivery, including the client’s perceived value in the proposed plan as a key determinant of whether patient care moves forward.³⁹

Moving beyond cost of care: a humanistic and holistic approach

There is a growing need for both a humanistic and a holistic approach to healthcare delivery, one that considers the client’s and cat’s physical, emotional, relational and cognitive needs. Decision-making about what is ‘best’ for the client/patient dyad must increasingly consider the client’s thoughts, concerns, core beliefs, values, perceptions and perspectives. Clients may vary tremendously in terms of what they consider to be an acceptable quality of life. In cases of terminal disease, clients may not always agree that life-sustaining measures are ‘right’ for the patient. Veterinarians must pivot in their application of evidence-based medicine to clinical casework to continually incorporate the client’s perspective and to be responsive to a broad range of needs. Spectrum of care invites dialogue about which management approaches are appropriate for each patient, client and situation, and why.¹

Forward planning with respect to individual cases requires us to consider the following client-, patient- and veterinarian-specific factors, other than cost. This list is not intended to be exhaustive, but rather serves as a starting point to invite conversation about the many constituents of spectrum of care (Figure 1):

Client-specific factors^104,111,112

○ Client’s health literacy: the degree to which individuals can find, understand and use information and services to inform health-related decisions and actions for themselves and others

– Understanding the medical needs of the cat¹¹³

– Understanding signs of pain in the cat¹¹³

○ Client’s goals

○ Culturally ascribed self-sufficiency and stoicism¹¹⁴

○ Cultural influences¹¹⁴

○ Client’s expectations

– Is the client expecting that treatment will be curative or palliative?

○ The client’s relationship with the patient

– Is the patient considered family? If so, in what way?

– Is the patient a living link to a loved one who is no longer alive? If so, how might that complicate decision-making?

○ Is the client able to comply with treatment recommendations?

– Is the client physically able to give pills to their cat?

– Is the client physically able to administer injections?

○ Does the client’s schedule allow them to comply with recommendations?

Can the client administer medications in accordance with the outlined schedule? For instance, can the client administer treatment six times a day?

Can the client return for rechecks as outlined by the veterinarian?

○ Client’s pet-specific expertise

– What is best for this cat and why?

– What will this cat tolerate and why?

– What actions are inappropriate for this cat and why?

– What is the cat’s perceived quality of life and will to live?

Client’s emotional capacity

– How is the client coping with the cat’s condition?

– How is the client navigating their role and responsibilities as a caregiver?

– Is the client able to find purpose as the cat’s primary caregiver?

– How much stress and uncertainty can the client endure?

– What is the impact of the patient’s decline on the client?

– Is the client succumbing to caregiver burden or does the client find purpose in their role/responsibilities?

○ Accessibility of care³⁵

– Does the client know where to seek care?

■ Is there a clinic within the vicinity or does the client reside in a care desert?¹¹⁴

■ Are there specialty clinics and emergency rooms within reach?

■ Is the distance or drive to specialty clinics a deterrent to pursuing care?¹

– Can the client commute to/from the clinic or are there ambulatory practices/mobile units?^36,¹¹⁴

– Does the client have the ‘equipment’ (eg, a suitable carrier) needed to safely obtain care?^36,114

○ What is the client’s risk tolerance?

– How comfortable would the client be in accepting a negative outcome based on decision-making?

■ How might the client react to a negative outcome that results from a decision to move forward with conservative care?

■ How might the client react to a negative outcome that results from a decision to move forward with an invasive procedure that ended in a procedural complication?

○ Are there trust issues that prevent care from moving forward?^36,114

○ Are there multiple caregivers who must collectively weigh in on decisions?

○ Are healthcare options in alignment with and/or feasible given the client’s core beliefs and values?

Patient-specific factors⁷¹

○ The patient’s purpose/function or ‘place’ in the household

○ The patient’s temperament¹¹⁵

○ The patient’s socialization to people

○ The patient’s tolerance of travel for veterinary care

○ How reactive the patient is at the veterinary clinic¹¹⁵

○ The patient’s tolerance for interventional care¹¹⁵

○ The patient’s actual illness or disease process

○ The patient’s prognosis, including, but not limited to, the likelihood of improvement

○ The influence of comorbidities

○ The patient’s quality of life

Veterinarian-specific factors³⁵

○ What is the clinic’s capacity to provide care?

– Impact of the veterinary workforce shortage

– Inability to provide care due to no available appointments or emergency clinic overload

○ Knowledge base, content areas of expertise, and exposure to updates in scientific evidence and professional guidelines

○ Explicit or implicit biases and assumptions that have been made with respect to the client’s ability or capacity to pay for patient care, limiting the options presented

○ Explicit or implicit biases and assumptions that have been made with respect to the client’s presumed level of commitment to the pet and the choices the client would likely make if offered³⁶

○ Concerns about meeting standard of care in the eyes of regulatory authorities¹¹⁴

○ Established workplace policies and standard operating procedures¹¹⁴

○ Being trained to practice ‘gold standard’ medicine by educators, teaching hospitals and tertiary institutions alike may potentiate feelings of guilt or shame if alternative options are offered and accepted

○ Geographical location may influence options available

○ Access to equipment: does the clinic have the tools and resources that are needed to obtain answers for the client?

– eg, radiography

– eg, ultrasonography

○ Advanced training requirement: does the clinic employ those with the actual skillset required to address and/or resolve the issue?

– eg, maybe the clinic has purchased an ultrasound machine but has not provided the veterinarian with the training that they require to perform abdominal and thoracic focused assessment with sonography for trauma (A-FAST and T-FAST) procedures

– eg, maybe a feline patient would benefit from a perineal urethrostomy to manage recurrent urinary tract obstruction,⁹³ but the employed veterinarians do not feel comfortable performing that procedure

○ Are there language barriers between the veterinary team and the client that prevent/inhibit informed decision-making?

Figure 1

Client-, patient- and veterinarian-specific considerations that factor into the spectrum of care approach to the practice of veterinary medicine

The goal of developing patient care plans is to construct various diagnostic and therapeutic pathways that are equitably acceptable. Care is contextualized rather than predetermined, recognizing that the so-called gold standard may not be ideal for this patient, owned by this client, experiencing these circumstances. There is freedom in breaking away from a prescribed approach when it lacks relevance to the individual, their perspective or their collective experiences. It is important to recognize that there is a range of acceptable approaches to care and that the gold standard is just one among them. Spectrum of care creates a safe, supportive space in which to decide which treatment is best for which patient and client, and reminds us that the status quo in terms of evidence-based medicine is rarely long-lived. Medicine is ever-evolving and what we once thought was best practice may no longer be so. Or, what we thought would never be appropriate could be appropriate in case-specific circumstances. For example:

Pharmacotherapy and decompressive cystocentesis, in concert with a low-stress environment, may alleviate urinary tract obstruction⁹³ in male cats without urethral catheterization.⁹⁶

Perineal urethrostomy surgery is an appropriate next step at the first or second urinary blockage (earlier than past recommendations).¹¹⁶

Conservative management of clinically stable cats that have ingested metallic sharp-pointed straight gastrointestinal foreign bodies is a viable treatment option.¹¹⁷

Many cats with patellar fractures can experience successful return to function with a period of rest that restricts jumping, compared with the high failure rate of pin and tension band surgical fixation.^118–120

Surgical management does not appear to be superior to conservative management in cats with pelvic fractures: outcomes, including pelvic canal narrowing, are similar.¹²¹

The combination of cage rest, analgesia and monitoring the patient’s elimination habits in cats that have sustained sacroiliac luxation fracture has a high success rate.¹²²

The combination of well-managed pain; dietary, environmental and activity modulation; physical therapy; and nutraceuticals can lead to successful outcomes in cats with hip dysplasia.¹²³

Cats with fibroadenomatous changes of the mammary gland can be managed medically, through administration of the progesterone antagonist aglepristone, even during pregnancy. Ovariectomy and/or total or partial mastectomy are not required for successful treatment.¹²⁴

Pyometra in cats can be surgically treated by ovariohysterectomy with success in a non-specialized hospital setting.^125,126

Open pyometra in cats can be successfully treated with aglepristone to clear uterine infection.¹²⁷

Final comments

Since the era of James Herriot, if not before, veterinarians have consistently been tasked with ‘negotiating “down” to what the client can afford’.² However, the perception that there is only one correct approach to case management is problematic because this implies a ‘pre-existing and definable hierarchy of value that is intrinsic to the treatment and exists outside of the context of the individual patient/client/vet professional triad’.⁷¹

Spectrum of care encourages practitioners to re-examine their approach to case management and embrace options as medically appropriate and evidence-based rather than lesser. This is the first step to acknowledging, identifying and overcoming barriers to care so that care is accessible by all people for all animals rather than holding clients and patients to a single standard.

Spectrum of care also reminds us to critically question the status quo when it comes to diagnostic and therapeutic ‘best practices’. Are ‘best practices’ truly supported by evidence?¹²⁸ Are they truly necessary?¹²⁸ Spectrum of care prompts us to consider what we know to be true and why, so that we actively re-examine evidence-based options and how we deliver choices to clients. Human healthcare is paving the way for veterinary medicine to do the same. The Choosing Wisely initiative by the American Board of Internal Medicine (ABIM) is the first of its kind to promote dialogue between providers and patients about overused or ineffective practices.¹²⁸ Since its launch in 2012, recommendations about overused tests and treatments have appeared in nearly 300 journal articles, with buy-in from over 80 medical specialty societies.¹²⁸ There is great value to questioning what recommendations we make and why, so patient outcomes can be driven by transformative healthcare that is not afraid to adapt to changing times and upgraded expectations.

Footnotes

Acknowledgements

The author thanks multimedia specialist Eric Beasley for partnership in co-designing Figure 1. The author also wishes to thank Teresa Graham Brett, Associate Dean of Diversity and Inclusion, for her partnership in co-designing the longitudinal Professional Skills coursework at the University of Arizona College of Veterinary Medicine pre-clinical curriculum, which prioritizes the conceptual framework surrounding spectrum of care.

Accepted: 8 October 2023

Conflict of interest

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

This work did not involve the use of animals and therefore ethical approval was not specifically required for publication in JFMS.

Informed consent

This work did not involve the use of animals (including cadavers) and therefore informed consent was not required. No animals or people are identifiable within this publication, and therefore additional informed consent for publication was not required.

ORCID iD

Ryane E Englar

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