Pragmatic/charity minded orthopaedic referral recommendations?

RE: Pragmatic/charity minded orthopaedic referral recommendations?

David Mills — Sun, 10 Dec 2023 20:29:47 GMT

[quote userid="11493" url="~/f/non-clinical-questions/30844/pragmatic-charity-minded-orthopaedic-referral-recommendations/243155#243155"]It is also the case that the expensive optics have deterred both first opinion vet and client from seeking an early referral, which then translates into more expense (sometimes unnecessary) at first opinion and a more difficult (hence more expensive) situation to resolve as the patient has deteriorated.[/quote]

I hear this a lot from referral practices and practitioners - "if only they'd referred earlier" / "GP vets shouldn't be taking out anal glands" / "We'll have to repeat the tests" - but the flip side of the coin is the ones you don't see that get better at first opinion level.

Also late referrals often are due to client factors rather than VS.

Early referrals of routine cases (e.g. dry eye, glaucoma which I've seen recently being done) also cost the clients far more than being successfully managed in first opinion.

So I think the number of cases that would end up similar or less expensive by early referral are very small, and there is a huge amount of confirmation bias in these types of statements (as well as the luxury of not having the referring vet in the room whilst the eye rolling is going on).

Fun fact - we referred one of our nurses' dogs for a condylar Y-fracture and one of the locking plates came off a week later that we then replaced with a normal DCP plate. Referral cost her a lot more in that scenario!

[quote userid="11493" url="~/f/non-clinical-questions/30844/pragmatic-charity-minded-orthopaedic-referral-recommendations/243179#243179"]Bitch spays are difficult. [/quote]

Technically they can be, but they aren't taught at al well at most universities. See my comments on another thread.

An excellent outcome should be expected but that doesn't make the surgery harder.

[quote userid="11493" url="~/f/non-clinical-questions/30844/pragmatic-charity-minded-orthopaedic-referral-recommendations/243179#243179"] Do I think that would be a bad thing? It's not a definite 'yes'. [/quote]

I'm sure it would be a wonderful thing for referral centres. But not for 99% of animals.

VetAudit details outcomes from bitch spays - search online.

Why on earth would anyone ever think they were a referral level procedure.

Fun fact - at college a pyo was referred for emergency surgery. Specialist, an excellent surgeon, of many years experience, did it. Bled intraop from both pedicles and cervix. He was humble enough to say it was because he hadn't done one for about a decade and wasn't the best person to do it.

[quote userid="3513" url="~/f/non-clinical-questions/30844/pragmatic-charity-minded-orthopaedic-referral-recommendations/243154#243154"]Just because a vet can do a particular procedure does not mean their outcomes/complication rates will be the same as another vet performing the same procedure.[/quote]

And neither does it mean they will be worse for straightforward procedures. I don't think its the norm for referral centres to have good long-term outcome data for their procedures (>12m). Without that, I'm not sure how you compare success rates (and most studies use different outcome measures anyway).

There was a paper detailing the learning curve for TTAs was something like 23 procedures. So a resident in a referral centre on their 10th would be expected to have a possibly worse outcome than a cert holder doing their 50th in primary care (even though the client is paying normally 1.5x for the former compared to the latter) - what I'm trying to say is that whilst specialists are excellent surgeons in the main, it doesn't mean that they are significantly better in all cases especially for procedures that someone else may carry out far more frequently. The comparison flips both ways.

RE: Pragmatic/charity minded orthopaedic referral recommendations?

Francisco Gomez — Sun, 10 Dec 2023 18:45:06 GMT

[quote userid="4181" url="~/f/non-clinical-questions/30844/pragmatic-charity-minded-orthopaedic-referral-recommendations/243159#243159"]should I be offering specialist referral for a spay?![/quote]

I don't think this add to the OP's question, but I'll answer it anyway.

It would depends on what you consider a routine procedure. Without diminishing the difficulty of a bitch spay, I would think the line is exactly there. Bitch spays are difficult. Not just because they are intra-abdominal surgery, but because the pressure of a expected excellent outcome is always there.

I used to enjoy them a lot, and I had my fair amount of sorting out post op bleeding from colleagues in the past. Both in primary care and in emergency services. I guess if we stopped doing them routinely, the first opinion de-skill trend would make them a specialist service. Do I think that would be a bad thing? It's not a definite 'yes'.

RE: Pragmatic/charity minded orthopaedic referral recommendations?

Rob Loxley — Fri, 08 Dec 2023 21:17:26 GMT

[quote userid="3513" url="~/f/non-clinical-questions/30844/pragmatic-charity-minded-orthopaedic-referral-recommendations/243154#243154"]There is value in a specialist referral even for the less complex cases[/quote]

Though the OP was asking about charity cases.

[quote userid="3513" url="~/f/non-clinical-questions/30844/pragmatic-charity-minded-orthopaedic-referral-recommendations/243154#243154"]Not every owner will want a specialist referral but it is important (for the owner's freedom of choice but also the individual vet's protection) that they have the option[/quote]

To join you in playing devils advocate, should I be offering specialist referral for a spay?!

RE: Pragmatic/charity minded orthopaedic referral recommendations?

Francisco Gomez — Fri, 08 Dec 2023 15:50:21 GMT

My experience from a few months in ophthalmology referral practice is that the so-called 'gold standard' is not the only option offered. Many more affordable options are usually offered taking into account their merit and disadvantages. It is also the case that the expensive optics have deterred both first opinion vet and client from seeking an early referral, which then translates into more expense (sometimes unnecessary) at first opinion and a more difficult (hence more expensive) situation to resolve as the patient has deteriorated.

RE: Pragmatic/charity minded orthopaedic referral recommendations?

Andy Moores — Fri, 08 Dec 2023 14:04:58 GMT

Hi Rob, I don't disagree with your sentiment (especially about deskilling GP practice), but just to play devil's advocate, even 'simple' procedures can be performed well and can be performed badly, with consequences for patient welfare if they are performed badly. Just because a vet can do a particular procedure does not mean their outcomes/complication rates will be the same as another vet performing the same procedure. There is value in a specialist referral even for the less complex cases. Not every owner will want a specialist referral but it is important (for the owner's freedom of choice but also the individual vet's protection) that they have the option. This is recognised in RCVS guidance which states that when it comes to referrals a range of options should be provided.

Regards fixed-prices, we pioneered this at my previous clinic many years ago when it was a rarity and it is really pleasing to see this is now common-place. At my new clinic all of our routine procedures are fixed-price and many have a surgical guarantee.

Pricing has been done-to-death on this forum recently (!) but don't automatically assume that a specialist referral is going to be more expensive than other options. I often come across GP practices charging more than we do for investigations and procedures.

RE: Pragmatic/charity minded orthopaedic referral recommendations?

Rob Loxley — Fri, 08 Dec 2023 08:33:22 GMT

[quote userid="19305" url="~/f/non-clinical-questions/30844/pragmatic-charity-minded-orthopaedic-referral-recommendations"]A a basic example, when gold standard THR is not feasible financially in the name of helping as many patients as possible, but a FHNE will provide good quality of life, albeit maybe a shorter one, the latter may have to be the route taken[/quote]

One might ask why that should need an orthopaedic referral. FHNE could (should?) be within the scope of general practice; certainly someone with an interest/cert/AP would surely do this without needing a specialist referral?

Maybe a similar question is have we deskilled 1st opinion practice away from basic orthopaedics and how do we fix this?, rather than getting specialists to charge less?
Are we investing in training our staff in this; do we have equipment appropriate to managing such cases, are we happy to recommend an approach which is not 'gold standard'?

The really more complicated orthopaedic cases may need a referral (but could be a cert holder, visiting AP etc), or need the treatment plan altering to become less complicated cases (eg amputation over repair, cage rest over intervention; accepting less than perfect outcomes).

Orthopaedic referrals do at least seem to be an area where fixed prices (rather than wide estimates) are now more commonplace

RE: Pragmatic/charity minded orthopaedic referral recommendations?

Andy Moores — Thu, 07 Dec 2023 15:51:42 GMT

Hi Charlie, I think most specialists have a pretty pragmatic approach to cases where funds are limited. It helps of course to communicate the expectations/limitations for any particular case up-front. The scenario you describe is not an uncommon one and FHNE would always be discussed as an alternative option alongside THR, with the pros and cons of both options being discussed (in my experience)

RE: Pragmatic/charity minded orthopaedic referral recommendations?

Arlo Guthrie — Thu, 07 Dec 2023 15:41:14 GMT

10%

RE: Pragmatic/charity minded orthopaedic referral recommendations?

Andy Moores — Thu, 07 Dec 2023 15:39:14 GMT

I’ll send the cheque in the post Arlo Thank you

RE: Pragmatic/charity minded orthopaedic referral recommendations?

Arlo Guthrie — Thu, 07 Dec 2023 14:59:38 GMT

charlievelyn - above my pay grade, but I had a call some months back from a pet owner who had been referred for treatment they couldn't afford, and wanted to know if I knew any alternative options.

I had just written this story about Andy Moores, so passed on the details: https://www.vetsurgeon.org/b/veterinary-news/posts/new-independent-orthopaedic-referral-practice-in-hampshire

Owner wrote to thank me later, which I am sure he would not mind me sharing:

I cannot thank you enough for introducing me to the truly wonderful Andy Moores near Basingstoke, whose Practice Opening you covered just a few months ago.

It was an inspired choice and we are deeply grateful for your trawling through your files late on a Friday afternoon, trying to help a complete stranger in a time of need - it was way beyond the call of duty, produced a remarkable outcome and was hugely appreciated.

Andy is a consummate and compassionate Surgeon who successfully operated on our small puppy's fractured elbow within days of our telecon - he and his whole Team were brilliant in every day and, despite the complexity of the three and a half hour Op, they never charged a penny more than the already very reasonable Estimate. Their practice premises are immaculate and all set in beautiful rural tranquillity with their very own miniature Stonehenge!