Some clients may opt to treat parvo at home to save money. Cost can be significant concern when treating a critical illness. Puppies infected with canine parvovirus are a common presentation to veterinary practitioners. These dogs (and their owners) are frequently a financial, emotional, and infectious disease management challenge for clinics. Accordingly, these patients can arrive at the hospital with unique needs, specifically, spectrum of care, defined as evidence-based care options along the socioeconomic spectrum.1,2 Considering varied pet owner challenges (and the impact of this on veterinary care) has always been a part of practice (sometimes a heart-breaking one), and the need for these cost- of-care-considerations has never been more critical than in today’s times. Incorporating EBVM Prior to the COVID pandemic, an article was published to raise awareness of the necessity for spectrum of care and to suggest initiatives to improve access to care for dog owners.1 One of the initiatives proposed was incorporation of evidence-based veterinary medicine (EBVM) into the spectrum of care decision-making. EBVM is beginning to gain traction in the profession and has been defined as, “the use of the best relevant evidence in conjunction with clinical expertise to make the best possible decision about a veterinary patient.”3,4 Clinical parvovirus case: Penny Both spectrum of care and EBVM may be novel concepts for many veterinarians (recent and more experienced graduates alike). To help drive home the practical applications, Penny serves as a case study, which includes some of the peer-reviewed options for spectrum of parvo care (in this case lower cost) from an evidence-based standpoint. Penny and her owners present on a busy Friday afternoon, (why is this always the case?), with the concern of acute onset vomiting and diarrhea. She is a female five-month-old mixed breed dog that has been with her owners for about a month. They report her vomiting started about two days ago and while she is not eating today, she typically eats a dry kibble diet. They obtained her from a local breeder and do not think she has been vaccinated; this is her first visit to a veterinary clinic. Index of suspicion for parvo viral enteritis is high and a positive parvo test confirms this. On Penny’s physical exam, she is responsive but quiet, temperature is normal, she is approximately five to seven percent dehydrated and has generalized pain on abdominal palpation. Her owners immediately raise their twin concerns, 1) cost, $500 is about their limit, and 2) they love Penny and want to do what they can for her. This is a familiar tune for many, and there are no shortage of routes to proceed, all of which can vary based on multiple factors. For the purposes of this article, and to highlight EBVM and spectrum of care, a few assumptions will be made about Penny moving forward. One of these being a complete blood count has revealed a significant (but not severe) neutropenia and she is an otherwise uncomplicated parvo case. Additionally, infection control aspects of parvovirus will similarly go undiscussed; however, review the American Animal Hospital Association (AAHA) infection control guidelines for further details.5 As there is now a diagnosis of parvo, details of her case have been revealed and spectrum-of-care (cost consideration) needs have been verbalized by her owners, we will implement EBVM and spectrum of care concepts step-by-step into cost options for Penny and her people. Step 1: One of the first steps in the EBVM process is asking a clinical question. In Penny’s case, this would center around reduced cost parvo care (i.e., reduce cost through outpatient vs. in-hospital therapy) and our major outcome of interest-survival. A specifically worded clinical question will focus the evidence search and help avoid “garbage in equals garbage out” search results. As such, creation of a PICO question is helpful.3,4 As many are not familiar with this acronym (PICO), a quick definition would be: P (patient or population), I (intervention), C (control or compare), and O (outcome). Even when the index of suspicion for parvo viral enteritis is high, a positive parvo test confirms this. Since we are interested in spectrum-of-care reduced cost options, our PICO question for Penny might be: In dogs with parvoviral enteritis infection (P), what is the impact of lower cost outpatient treatment (I) as compared with inpatient hospitalisation (C) on patient survival (O)? Step 2: Next, acquire appropriate scientific literature utilizing the PICO question and assessing it. Here, I have skipped the literature search portion of this process and presented instead the identified articles with their key takeaways, ideally, strength of evidence and study limitations would also be completed.6 Based on the table on page 38, outpatient (at-home) treatment of parvovirus does reduce survival when compared to in-patient treatment in the veterinary hospital. However, outpatient parvo therapy (survival approximately 75 to 80 percent dependent on study and protocol) may be acceptable for some clients following communication regarding outcomes and risk factors.7-9 Within this spectrum of care scenario, Penny’s owners would be advised there may be reduced survival with OP care vs. in-patient protocol (survival approximately 90 percent).7 Communication around OP treatments at home should occur, i.e., can be time and labor-intensive due to patient nursing care needs, and may also include in-clinic assessment, regular communication, etc. Additionally, if Penny were younger (<four months), small (<4 kg) or presenting with severe disease signs, her chances of survival on the OP protocol might be further decreased.7-9 Step 3: Spectrum-of-care cost options. Listed below are examples of spectrum-of-care cost ranges for three treatment options (<$100, $100-$500, > $500) and summarized client communication. Please note prices listed are approximates and will vary based on regional fee guidelines. Option 1: Penny’s owners have less than $100 Communication with clients: Unfortunately, due to the nature of parvovirus it is unlikely puppies will survive without significant (OP or IP) supportive care. If finances are limited to this degree, and particularly in scenarios where the patient has risk factors for negative outcome and reduced survival (i.e., young, small breed, etc.), then other access to care strategies or euthanasia should be considered. Euthanasia: $87.50 Total: $87.50 Option 2: Penny’s owners have $100-$500 Communication with clients: At-home care (OP) for parvovirus can be intensive (time and labor). It will require someone to be at home with the puppy to ensure temperature and hydration status are controlled. Survival on the OP protocol was 80 percent,7 but dependent on region and fees, modification of the complete protocol to meet owners cost limit of $500 may be required, which could impact (likely reduce) survival rate. Consultation: $71.90 Parvo test: $50 PCV and total protein once: $22.80 Complete blood count once: $67.80 Venous blood gas and electrolytes once: $50 Medications: $150 Food: $50 Home supplies: $20 Total: $482.50 Option 3: Penny’s owners have $500+ Communication with clients: Based on EBVM, IP care provides the best survival outcome; however, parvo is a serious disease, and her prognosis remains guarded. The IP treatment outlined below was taken from the inpatient protocol used in the randomised control trial.7 It is the protocol likely comparable to the treatment protocols used in many facilities of a similar standard. Survival on this protocol was 90 percent.7 (Click to enlarge.) Consultation: $71.90 IV set up and maintenance: $166.70 IV maintenance for two to three days: $131.80-$197.70 Hospitalisation with extensive care for three to four days: $229.50-$306 Daily treatment with multiple injections three to four days: $170.10-$226.80 Faecal flotation: $28.50 Parvo test: $50 PCV and total protein three to four days: $68.40-$91.20 CBC three to four days: $203.40-$271.2 Venous blood gas and electrolytes three to four days: $150-$200 Medications: $200 Total: $1,470.30-$1,810. (Again, dependent on hospital protocols for infection control needs for parvovirus puppies.) What happened next for Penny the parvo puppy? In our fictional case setting, Penny’s owners can have someone at home to care for her and proceed with the second option above, i.e. OP care. Fortunately, the puppy improves over the following three days with diligent home care and regular communication with the clinic. Spectrum-of-care plans for the longer term are next initiated to ensure she is dewormed, vaccinated, and receives age- and region-appropriate preventive care. Puppies with parvovirus are one of the most common clinical presentations of infectious GI disease in unvaccinated dogs, particularly young dogs.10 These patients can present with a variety of clinical signs that range in severity, which makes therapy choices and discussion with owners even more challenging. An EBVM-approach can assist with management decision-making for these patients and allow for incorporation into a spectrum of care approach with practical cost ranges. As always, it is important to document veterinary-client communications during our work to facilitate the human-animal bond. With respect to spectrum-of-care, most (all?) of us have been there, i.e., had our hands tied for various reasons, cost, and other. We, as a profession, need to celebrate we have unique competencies allowing us to assist these patients (and clients) and cheer on veterinary curriculum additions on these topics.1,2 Michelle Evason, BSc, DVM, DACVIM (SAIM), is a small animal internal medicine specialist and consultant. She has worked in general practice, specialty clinical practice and academia, and in the animal health and pet food industry. Dr. Evason has a range of clinical and research interests and has published on numerous infectious diseases, antimicrobial stewardship, nutrition, and pet-owner education-related topics. References Stull JW, Shelby JA, et al. Barriers and next steps to providing a spectrum of effective health care to companion animals. J Am Vet Med Assoc. 2018. 253: 1386-1389. Fingland RB, Stone LR, et al. Preparing veterinary students for excellence in general practise: building confidence and competence by focusing on spectrum of care. J Am Vet Med Assoc. 2021: 259: 463-471. Launching an evidence-based veterinary medicine manifesto to drive better practise. Vet Rec. 2020: Sep;187 (5): 174-177. Centre for Evidence-based Veterinary Medicine web site. Accessed February 2021. https://www.nottingham.ac.uk/cevm/about-the-cevm/evidence-based-veterinary-medicine-(evm).aspx. Evidence-based veterinary toolkit, RCVS. As accessed August 2021. https://knowledge.rcvs.org.uk/evidence-based-veterinary-medicine/ebvm-toolkit/ AAHA Infection Control guidelines. As accessed August 2021. https://www.aaha.org/aaha-guidelines/infection-control-configuration/aaha-infection-control-prevention-and-biosecurity-guidelines/ Evason M. Canine parvovirus: Updates on evidence-based spectrum of care therapy considerations. 2021. Emerald Coast Veterinary Conference Proceedings. Accessed August 2021: https://ecvc.memberclicks.net/assets/73183%20ECVC_complete%20book_low%20res.pdf Venn EC, Preisner K, et al. Evaluation of an outpatient protocol in the treatment of canine parvoviral enteritis. J Vet Emerg Crit Care. 2017. Jan 1;27(1):52–65. Sarpong KJ, Lukowski JM, et al. Evaluation of mortality rate and predictors of outcome in dogs receiving outpatient treatment for parvoviral enteritis. J Am Vet Med Assoc. 2017. Nov 1;251(9):1035–41. Perley K, Burns C, et al. Retrospective evaluation of outpatient canine parvovirus treatment in a shelter-based low-cost urban clinic.J Vet Emerg Crit Care. 2020: 1-7. Weese JS, Evason M. Infectious Diseases of the Dog and Cat. CRC Press. July 2019.
