Spectrum of Care- What is it and why should I care?

I am preparing a number of conference presentations for this year, and one of the new ones is on the topic of Spectrum of Care. This is a concept I have been involved this for a while, since participating in a working group organized by a classmate of mine that culminated in a publication kicking off a discussion about balancing the needs of patients and the rising costs of veterinary care.

Below are some thoughts on the subject. If you want more, I will be talking about this (and lots of other topics) at the Pacific Veterinary Conference in San Francisco July 11-12, 2024.

WHAT IS SPECTRUM OF CARE?

The core of the Spectrum of Care (SOC) concept is recognizing that the treatment of each patient takes place in a unique context that includes the patient, the client, and the veterinarian.^1–3 There is no single, universal “gold standard” that can be automatically applied to every patient. A key role for the practitioner is to identify the best approach for a specific case by integrating-

• the needs of the patient 
• the goals and capacity of the client 
• the vet’s knowledge and skills
• the relevant scientific evidence concerning diagnostic and treatment options

An articulated spectrum of care approach should provide support and guidance to practitioners and ensure consistent and explicit consideration of all relevant information by both vets and clients. Vets provide recommendations for managing the case, always relying on an evidence-based understanding of the needs of the patient and of the risks, benefits, and uncertainties associated with the available interventions. These recommendations are then adapted to the goals and capacity of the owner through an explicit shared decision-making process. 

The impact of the approach ultimately chosen on the wellbeing of the patient is then regularly re-assessed, and the plan is adjusted as needed throughout the course of treatment. Such adjustment always involves clear discussion between the vet and the client about all relevant issues, including the apparent benefits and adverse effects on the patient, the caregiver burden, the practical and economic sustainability of treatment, and the ultimate goals as understood by the vet and the owner.

PATIENT FACTORS

The needs and quality of life of the patient are always the central focus of medical care. These should be assessed in as objective and evidence-based a way as possible. The use of clinical metrology instruments, such as pain scales and quality of life tools, can help veterinarians and owners gain a more accurate common understanding of how the patient is doing and what they need.^4,5

While veterinary patients cannot intellectually understand their condition and consent to treatment, they do have feelings and reactions to their care that must be taken into account. If a patient has a strong fearful or aggressive reaction to treatment, or if assessment suggests that treatment itself is negatively affective quality of life, alternative approaches should be considered. 

Because our goal is to maintain or to reestablish a state of comfortable living in which patients can experience the activities and interactions they enjoy, all possible efforts should be made to ascertain what a good quality of life is for a given patient and to align the veterinarian’s and the clients’ understanding of this to the greatest extent possible. This will help guide the choices both parties make among the spectrum of care options available.

CLIENT FACTORS

The factor vets think about most often when considering the impact of clients on the treatments we can use is money. There is no question that financial constraints very often limit which tests and treatments can be employed, and clinicians must be adept at finding ways to meet the patient’s needs and the clients’ goals while not undermining the financial viability of their own practices. 

An explicit spectrum of care approach that supports early and open discussion of such issues can help avoid wasting limited resources on tests that will not change the treatment plan or outcome and on treatments that are not effective or sustainable for the client. The sooner and more openly we talk about the availability of multiple paths towards achieving an acceptable outcome for the patient, the more efficiently we will choose and begin following the right path.

Money is not, however, the only client variable that impacts the choice of treatment. There is a growing literature concerning caregiver burden, which includes the physical, social, and emotional impact of caring for a sick pet as well as the financial costs.^6,7 There are even instruments for measuring caregiver burden. Expanded development and use of these could be very helpful for vets and clients in understanding the overall constraints on care options and in making more thoughtful and effective choices. 

The personal beliefs and values of clients can also affect their care decisions. Clients who have misconceptions or misunderstandings about the safety and effectiveness of medical treatments may need to be educated to inform better choices. And clients who have strong ideological or spiritual beliefs related to healthcare may choose some options and eschew others to stay consistent with these beliefs, regardless of the scientific evidence. 

This can be frustrating when the veterinarian has a very different understanding of the situation. Seeing a patient suffering because a client is opposed to potentially beneficial therapies or categorically rejects the option of euthanasia is just as distressing for vets as when a client cannot afford needed care for their pet. 

We cannot always achieve what feels like an optimal outcome for our patients in these situations. However, an explicit SOC approach with an emphasis on open communication about such issues and about all the available options may lead to better outcomes for patients than the extremes of an absolutist “my way or the highway” approach or a complete surrender to whatever the client demands.

VETERINARIAN FACTORS

In order to offer a range of diagnostic and treatment options that will effectively address the patient’s needs, vets must be aware of the options available and the risks, benefits, and uncertainties for each. An accurate, evidence-based understanding of these is essential, because offering ineffective treatments or avoiding those that actually work can never benefit patients. Our role in the VCPR is to understand what the patient needs and how we can best achieve this from a science-based perspective that is not directly available to the owner. We then need to advocate for the patient and educate the owner to provide them with the perspective and information necessary for making appropriate care choices.

Just as the client has constraints on their capacity to utilize particular treatments, so vets are constrained by their own knowledge and skills and by the resources available to them. The optimal therapy for a given case may not be available if it involves drugs or equipment the vet doesn’t have, techniques they are not familiar with, or staffing resources that exceed what is available in their practice. 

The majority of veterinary assessment and treatment occurs in primary care practices, and this is where the implementation of an SOC approach from the initial encounter is especially needed. Optimal management of a particular patient may be possible in general practice, or it may require some level of specialty consultation or referral.⁸ One key component of SOC is determining if and when referral may benefit patients and how to achieve the best possible outcome for them when this is not an option. Often, the utility of referral is determined not only by the medical needs of the patient but by the capabilities of the practitioner, the goals and capacity of the owner, and the nature of communication within the VCPR.

COMMUNICATION ABOUT SPECTRUM OF CARE

Veterinarians are essential for effective patient care because we have the medical knowledge to understand the needs of the patient and to offer treatments to meet these. This does not, of course, mean that the client factors already discussed are not critical. The client can often understand the needs of the patient from a perspective not accessible to the veterinarian, and aligning these two perspectives is a key goal of the shared decision-making process. Just as the client cannot make effective decisions without accurate information about their options, the veterinarian cannot offer the most useful guidance if they do not understand and incorporate the clients’ perspective and needs into their recommendations.

To support the best possible care choices, the owner should understand the risks, benefits, and costs of intervention and the expected outcome associated with different approach, as well as the degree of uncertainty involved. The vet should understand the owners’ beliefs, expectations, and limitations well enough to recognize whether recommended interventions can be successfully employed or not. If a particular approach is unlikely to be effective due to client or patient factors, then alternative approaches to obtain an acceptable outcome should be considered and discussed.

Veterinarians are already accustomed to the negotiation and compromises between what they may see as the medically optimal approach and what clients are able or willing to do. However, such compromises are often made in an idiosyncratic manner, according to the particular beliefs, experiences, and habits of the individual clinician. The focus is usually on the financial constraints imposed by the client and how this hampers the “gold standard” care that a vet would like to provide. This process is often framed as a veterinarian recommending the optimal medical treatment and the owner declining, with the vet ultimately agreeing, shamefully or with resignation, to a cheaper and less appropriate treatment approach. 

This pejorative view mischaracterizes a necessary process and can leave both clinicians and owners feeling they have failed to provide good care for the patient. It also hampers thoughtful decision making and open communication, which could make the inevitable compromises more rational as well as less unpleasant for everyone.

The concept of a medical “gold standard” is mostly mythical and counterproductive.⁹ There are no universal treatment approaches that can be automatically applied to every possible case. Veterinary students are still trained predominant­ly by specialists in tertiary care facilities, often learning their craft from the least representative exemplars of the profession and seeing patients and interventions very different from those common in general practice. This creates a clash of expectations and perspectives that must be resolved once new graduates enter a pri­mary care practice environment.⁸ One goal of the SOC approach is to legitimize the inevitable differences between these practice contexts and diminish the perception that tertiary care represents to optimal or most appropriate approach while primary care is a lesser, fallback alternative. 

Vets need support in developing the communication skills necessary to build effective VCPRs in a diverse client population with varied beliefs, goals, values, and constraints on the care they can provide for their pets. The SOC approach is aimed specifically at providing this support and normalizing the process of developing a management plan within the unique context of each case without the stigma that is currently attached to this process. Official recognition of the value and legitimacy of a SOC approach can also protect veterinarians from the anxiety that they will be punished, legally, financially, or in reputation, for appropriately adapting the available treatment options to the circumstances of each case.

THE ROLE OF EVIDENCE-BASED MEDICINE IN SOC

The lack of a single universal approach which all vets should employ reflexively does not, of course, mean that general principles and guidelines are not useful. These can be extremely helpful to inform decision-making, especially in characterizing the needs of the patient and the risks and benefits of various possible interventions. 

Options included within the spectrum of care choices must be effective, and this means not only acceptable to the client and the veterinarian but also with a demonstrably positive balance between risks and benefits. Scientific evidence and the processes of evidence-based medicine are the best tools to identify the patient needs and the strengths and weaknesses of various treatment options.¹⁰

The SOC approach also does not render all such options equally appropriate. There are still “wrong” choices, from both a scientific and an ethical perspective. Ineffective treatments, or those which do more harm than good, are no more acceptable within the SOC approach than treatments which the client cannot afford or which the patient cannot tolerate. The discretion of the clinician to adapt general guidelines to the context of a specific case is constrained by scientific truth as well as by the resources or choices of the client.

The development and greater use of evidence-based clinical practice guidelines and tools for assessing quality of life and caregiver burden can facilitate a beneficial SOC practice. More research is also needed to characterize the risks and benefits of alternative treatment approaches for specific conditions. For example, studies comparing patient outcomes between routinely recommended and alternative, less intensive and expensive, treatments for canine parvoviral enteritis and for urinary tract obstruction in cats illustrate how such information can inform discussions between vets and owners about the pros and cons of various treatment options.^11,12

Less aggressive treatment may have lower chances of a desired outcome, and clients should know this. However, the chances of a good result are still likely to be greater than when euthanasia is chosen over care that the client cannot afford or the veterinarian cannot provide. And less intensive care may also have fewer adverse effects and a lower caregiver burden, which could provide for better quality of life for the pet even if, in some cases, the length of life might be shorter. Such tradeoffs are inevitable and already commonly made, but vets and clients cannot make them effectively and maximize the potential for acceptable patient outcomes without accurate information indicating the risks and benefits of various approaches.

CONCLUSIONS

Offering a spectrum of care options that meet patient needs and aligns with the goals and capacity of vets and clients is not a revolutionary new idea. Vets have been negotiating the best approach for the unique circumstances of each case forever. 

However, SOC is also not the same old thing we have long been doing. The usual negotiations depend very much on the idiosyncratic beliefs, experiences, and personalities of individual veterinarians. What interventions we offer, how we anticipate or respond to constraints imposed by clients, and how we manage the critical communication within the VCPR all depend on ad hoc approaches we each develop individually. 

An articulated SOC approach emphasizes an evidence-based understanding of the options available, explicit and open communication about what the patient needs and what the vet and the owner can provide, and shared decision-making for how best to achieve a good outcome for the patient within the inevitable constraints of circumstances. SOC brings structure and transparency to this process and removes the shame created by the myth of a universal “gold standard” for care and the indoctrination in school that tertiary care practices represent the ideal for which all vets should strive.

A concerted effort will be needed, however, to make sure SOC does not just become an empty buzzword. Vets need tools to assess patients, evidence to characterize the pros and cons of various treatment options, training and support in client communication and shared decision-making, and backing from veterinary organizations to support implementing SOC as a routine process. 

More evidence also needs to be developed to elucidate the risk and benefits of an SOC approach and determine if this practice really improves greater accessibility and quality of veterinary care for patients. Like all apparently good ideas, the real the value of SOC needs to be demonstrated empirically. 

For now, the rationale for the approach, and for building the necessary evidence, tools, and support systems to implement, seems strong, and the potential to improve the experience of all parties in the VCPR seems promising.

REFERENCES

1.         Stull JW, Shelby JA, Bonnett BN, et al. Barriers and next steps to providing a spectrum of effective health care to companion animals. J Am Vet Med Assoc. 2018;253(11):1386-1389. doi:10.2460/javma.253.11.1386

2.         Brown CR, Garrett LD, Gilles WK, et al. Spectrum of care: more than treatment options. J Am Vet Med Assoc. 2021;259(7):712-717. doi:10.2460/javma.259.7.712

3.         Fingland RB, Stone LR, Read EK, Moore RM. Preparing veterinary students for excellence in general practice: building confidence and competence by focusing on spectrum of care. J Am Vet Med Assoc. 2021;259(5):463-470. doi:10.2460/javma.259.5.463

4.         Alves JC, Santos A, Jorge P, Lavrador C, Carreira LM. Evaluation of Four Clinical Metrology Instruments for the Assessment of Osteoarthritis in Dogs. Anim Open Access J MDPI. 2022;12(20):2808. doi:10.3390/ani12202808

5.         Schmutz A, Spofford N, Burghardt W, De Meyer G. Development and initial validation of a dog quality of life instrument. Sci Rep. 2022;12(1):12225. doi:10.1038/s41598-022-16315-y

6.         Spitznagel MB, Carlson MD. Caregiver Burden and Veterinary Client Well-Being. Vet Clin North Am Small Anim Pract. 2019;49(3):431-444. doi:10.1016/j.cvsm.2019.01.008

7.         Silva PTRF, Coura FM, Costa-Val AP. Caregiver Burden in Small Animal Clinics: A Comparative Analysis of Dermatological and Oncological Cases. Anim Open Access J MDPI. 2024;14(2):276. doi:10.3390/ani14020276

8.         McKenzie B. Do it yourself or send for help? Considering specialty referral from a general practitioner perspective. J Am Vet Med Assoc. Published online January 3, 2024:1-6. doi:10.2460/javma.23.11.0612

9.         Englar RE. The Gold Standard, Standards of Care, and Spectrum of Care. In: Low-Cost Veterinary Clinical Diagnostics. John Wiley & Sons, Ltd; 2023:1-8. doi:10.1002/9781119714521.ch1

10.      McKenzie B. Evidence-based veterinary medicine: What is it and why does it matter? Equine Vet Educ. 2014;26(9):451-452. doi:10.1111/eve.12216

11.       Cooper ES, Owens TJ, Chew DJ, Tony Buffington CA. A protocol for managing urethral obstruction in male cats without urethral catheterization. J Am Vet Med Assoc. 2010;237(11):1261-1266. doi:10.2460/javma.237.11.1261

12.      Venn EC, Preisner K, Boscan PL, Twedt DC, Sullivan LA. Evaluation of an outpatient protocol in the treatment of canine parvoviral enteritis. J Vet Emerg Crit Care San Antonio Tex 2001. 2017;27(1):52-65. doi:10.1111/vec.12561