Contextualised or pragmatic medicine?

RE: Contextualised or pragmatic medicine?

Cinzia Gandini — Thu, 09 May 2024 23:05:25 GMT

[quote userid="11308" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244541#244541"]That is a reference to a previous paper[/quote]

do you have recent references? Because I have 2021 study in dogs with DMVD ACVIM B1

""In conclusion, pimobendan has reducing effects on the concentrations of pre- and post-exercise cardiac biomarkers and on the size of the left ventricle in dogs with DMVD in stage ACVIM B1. In addition to this, most owners described their dogs as being more active under pimobendan treatment.""

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8467240/#:~:text=Pimobendan%20had%20reducing%20effects%20on,treatment%20in%20dogs%20with%20DMVD.

RE: Contextualised or pragmatic medicine?

Rob Loxley — Thu, 09 May 2024 21:32:30 GMT

And you really don’t need a cardiology certificate or a super whizz machine to do the measurements needed!

RE: Contextualised or pragmatic medicine?

Anthony Dennison — Thu, 09 May 2024 21:15:23 GMT

[quote userid="4103" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244523#244523"]

I was just reading the first 1. reference article, quote

Background: Pimobendan is effective in treatment of dogs with congestive heart failure (CHF) secondary to myxomatous mitral valve disease (MMVD). Its effect on dogs before the onset of CHF is unknown.

[/quote]

That is a reference to a previous paper, which the EPIC trial sought to see if there was any effect.

The positive impact on pre-clinical pimobendan for dogs in Stage B2 CHF was so profound they ended the trial early because the benefits were so profound the authors felt it was unethical for the placebo group to not get the drug as well. There has since been long term follow up studies from the EPIC trial showing the benefits of this.

I will offer a scan, if the owner declines I say to monitor resting respiratory rate and look out for signs of CHF.

If I scan the dog and it is in B1, could scan it annually, or just look for signs of CHF and start once this happens.

A dog shown to be in B2 on a scan is started on pimobendan. Doesn't need a rescan, you know it has heart failure, just add in additional drugs when clinical signs start.

I heard an interesting snippet watching some cardiology lectures on Central CPD - only 15% of dogs with murmurs related to MVD actually go in to clinical heart failure, so why treat them at all if you don't know they are B2?

RE: Contextualised or pragmatic medicine?

Beats — Wed, 08 May 2024 21:54:16 GMT

[quote userid="14379" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244531#244531"]On the concept of pimobendan. A recent cpd showed that the cost of unnecessary treatment can be much more than an echo to accurately stage. I’ve not used pro bnp since graduating. The other thing coming from cpd is that it can actually be harmful to use it in those cases where they don’t need it yet. Such as stage b1. So we have to be careful in regards to these comments also [/quote]

I think pimobendan deserves a new thread, as this converstiaon is worth continuing in its own right.

My thoughts:

An old vet years ago, mainly large animal, used to start dogs with murmurs on pimobendan because he could hear their hearts loud on both sides of the thorax, and thus concluded that they likely had enlarged hearts.

I thought this very silly and uneducated. Most of these dogs had never been clearly shown to be in left-sided congestive heart failure as evidenced by both clinical signs and xrays consistent with pulmonary edema.

A good cardiologist would spend most of their time taking dogs off pimobendan that had not been shown to have previously been in congestive heart failure.

There was no evidence that pimobendan helped dogs unless they had been seen to be in congestive heart failure. It was a waste of money and may be harmful.

But now we are much cleverer.

We now know that pimobendan helps a high proportion of dogs with stage B2 mitral valve disease (prior to onset of clinical signs of pulmonary edema) to live longer and prosper.

We know from experience that pimobendan is one of the drugs which, for whatever reason, we don't recognise dogs getting side effects from with any regularity at all - to the extent that the cynic would question with the lack of side effects in the dog, are we sure it is doing anything at all and not merely the success of an unknown positive publication bias.

Now we know to start a dog on pimobendan at the moment it enters our classification of B2 mitral valve disease, and not a moment earlier, because we have no evidence it will help a dog prior to this point and it is expensive and may do harm.

Indeed, to be purists, we must match the inclusion criteria of the study population in whom a benefit was overall seen, as unless we do we can't be sure of translation of those results to our patient.

But pimobendan is not expensive any more. For a 10kg dog, taking a quarter of a 10mg cardisure twice daily, for example, we are talking £20 a month, or £240 a year (https://www.animeddirect.co.uk/cardisure-flavoured-tablets).

That is not much more than the cheapest of heart scans being offered, and the price of heart scans is likely increasing while the cost of pimobendan is likely decreasing.

And how often are we scanning the heart - we don't wish to miss the start of the go, go, go time for pimobendan stage B2. If we rescan a B1 every 6 months, then this is costing more per year than the pimobendan likely would, and the balance of pimobendan doing unrecognised harm versus potential benefit is probably tipped more towards the potential benefit category anyway (either because it might help some dogs where it has not yet been proven to, or it might be started sooner than it would if delayed for a re-scan in dogs where it has been proven to help).

And that's before we factor in the potential of a heart ultrasound to do harm. I'm going to go out on a limb here, for the sake of controversy, and say that the risk of harm from a heart ultrasound may exceed the risk of harm from "premature" pimobendan. That may not be the case, but it is a factor that needs to be recognised. Otherwise you end up with an analysis like the vaccine serology one that failed to take into account the risk to dogs from taking a blood sample, which is wrongly assumed to be zero, rather than extremely low, and thus contrasted perhaps erroneously favourably with the extremely low risk from the vaccine.

I do as per Gillian,

1) Heart scan

2) Pimobendan wihout a scan

3) Only if develops CHF.

I explain in less than 3 minutes the options, read the owner as best I can and make my best recommendation from that.

e.g.

"Ideally we'd do a heart scan at this point to see if Fluffy would benefit from starting a medicine now to help her heart work for longer with its leaky valve, but if you're not keen for the cost of it, we can consider starting on the medicine without knowing if she needs it at this point. we don't tend to see side effects from this medicine and even if she doesn't need it now, she might start to need it later - it's not ideal to start a medicine that she doesn't need now, but it is a reasonable option, and is usually cheaper than repeated heart scans. We know that some dogs definitely benefit from going on this medicine before they show signs of illness from their leaky heart valve, such as shortness of breath, but a couple of decades ago we didn't know that and would have only treated the ones having obvious difficulties - it's not my preferred approach these days, but if you aren't keen for any expense just now, you can decide not to treat unless the leaky valve causes problems - it doesn't always."

RE: Contextualised or pragmatic medicine?

David Mills — Wed, 08 May 2024 19:50:32 GMT

[quote userid="14379" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244531#244531"]The other thing coming from cpd is that it can actually be harmful to use it in those cases where they don’t need it yet[/quote]

What was the evidence presented for this statement?

RE: Contextualised or pragmatic medicine?

skatealexia — Wed, 08 May 2024 18:11:54 GMT

On the concept of pimobendan. A recent cpd showed that the cost of unnecessary treatment can be much more than an echo to accurately stage. I’ve not used pro bnp since graduating. The other thing coming from cpd is that it can actually be harmful to use it in those cases where they don’t need it yet. Such as stage b1. So we have to be careful in regards to these comments also

RE: Contextualised or pragmatic medicine?

Cinzia Gandini — Wed, 08 May 2024 18:02:50 GMT

[quote userid="2457" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244528#244528"]evidence based medicine[/quote]

I totally agree with you, that's out of discussion, we are not discussing the indications and the effectiveness of a medicine, but the choice of a procedure and therapy for that client with that pet with that disease, and in particular when it looks advisable to go for a contextualizing care. In this respect I think the whole process needs our experience and everything we know about our client, to be very sure to cure the dog and not the disease.

RE: Contextualised or pragmatic medicine?

Gillian Mostyn — Wed, 08 May 2024 16:10:32 GMT

[quote userid="4103" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244523#244523"]I think own experience is very important if you want to pursuit contextualizing care. One thing is what it's written in trials carried out by the same pharmaceutical company, or found in literature, another thing is medical field experience.[/quote]

We're actually pretty poor at auditing our own outcomes - usually having rose tinted spectacles and confirmation bias.

I'm all for using experience to guide my decision making and advice to clients - its really valuable to discuss your own experiences. But when it comes to giving clients information about the benefits and risks of medication and specific treatments, I do think we should be using evidence based medicine.

RE: Contextualised or pragmatic medicine?

Gillian Mostyn — Wed, 08 May 2024 16:04:34 GMT

[quote userid="2675" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244524#244524"]the inconvenience of giving medication twice a day for most working families, holidays. [/quote]

I think someone who finds medicating their pet too inconvenient is not looking for any care at all really - we're not magicians!

RE: Contextualised or pragmatic medicine?

Gillian Mostyn — Wed, 08 May 2024 15:53:04 GMT

[quote userid="2675" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244524#244524"]So can we talk about the costs of bloods, proBnp, ultrasound, ecg, repeat monitoring and monthly pimobendan for , say 10 years? [/quote]

10 years is optimistic!

But id say this care can be contextualized! One option is all the tests you mention. Another is to do a heart scan. The other is to start pimobendan earlier rather than later in MVD, with the idea that if its too early it won't do any harm. That's usually less than £1 per day.

I think looking at these things as 'do everything' or 'do nothing' is part of the problem.

RE: Contextualised or pragmatic medicine?

Cinzia Gandini — Wed, 08 May 2024 13:46:04 GMT

[quote userid="2675" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244524#244524"] the costs[/quote]

https://www.bsecho.org/common/Uploaded%20files/Education/Posters/PUA005%20-%20article.pdf

I really loved this reading it's human medicine, British Journal of general practice. And I liked this sentence

An overreaching principle of medicine is that the result of any investigation should have a significant impact on a patient’s management

RE: Contextualised or pragmatic medicine?

Richard Carter — Wed, 08 May 2024 13:43:07 GMT

Yes Gillian- absolutely correct about the research.

So can we talk about the costs of bloods, proBnp, ultrasound, ecg, repeat monitoring and monthly pimobendan for , say 10 years? Also the costs of taking time to get the patient to the practice, the inconvenience of giving medication twice a day for most working families, holidays. With insurance now putting limits on conditions and premiums exceeding £1000/ year when the electricity and other household bills are biting…

I’ve lost count of the number of clients who treat the first pet to this level and put the next to sleep. Same with diabetics, lymphoma and other intensive care conditions and we haven’t even mentioned referrals

RE: Contextualised or pragmatic medicine?

Cinzia Gandini — Wed, 08 May 2024 13:18:11 GMT

[quote userid="2457" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244522#244522"]My experience is irrelevant in this case[/quote]

I think own experience is very important if you want to pursuit contextualizing care. One thing is what it's written in trials carried out by the same pharmaceutical company, or found in literature, another thing is medical field experience.

I was just reading the first 1. reference article, quote

Prolongation of preclinical period by approximately 15 months represents substantial clinical benefit.

Sorry for editing I wanted to keep it in one post

RE: Contextualised or pragmatic medicine?

Gillian Mostyn — Wed, 08 May 2024 12:25:57 GMT

[quote userid="4103" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244518#244518"]In your experience what % of dogs add up a consistent number of years survival (good life worth living) compared to dogs that didn't undergo an amount of tests and investigations scans etc, considering the average age is 16 if that and anyway after that age some consider euthanasia regardless and/or for other reasons?[/quote]

My experience is irrelevant in this case.

https://www.epictrial.com/

I'm all for not extending poor QOL, but the results were pretty definitive. If it were my dog, and starting the drug led to longer survival with good QOL for longer, I'd want my vet to offer me that option. I'm not suggesting it's right for all cases, but it is for some.

RE: Contextualised or pragmatic medicine?

Cinzia Gandini — Wed, 08 May 2024 11:50:36 GMT

[quote userid="8991" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244516#244516"]Contextualised doesn't really mean anything[/quote]

It's all coming from the human medicine and then adapted to the vet field

https://www.sciencedirect.com/science/article/pii/S0738399121004158

https://www.mdpi.com/2227-9032/3/1/50

https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-021-05084-0#:~:text=Pragmatic%20care%20trials%20provide%20a,knowledge%20will%20eventually%20be%20found.

RE: Contextualised or pragmatic medicine?

Cinzia Gandini — Wed, 08 May 2024 11:36:54 GMT

[quote userid="2457" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244515#244515"]This a poor example[/quote]

I think it’s a great example, early investigations add up a big bill to get to what exactly? In your experience what % of dogs add up a consistent number of years survival (good life worth living) compared to dogs that didn't undergo an amount of tests and investigations scans etc, considering the average age is 16 if that and anyway after that age some consider euthanasia regardless and/or for other reasons?

RE: Contextualised or pragmatic medicine?

David Mills — Wed, 08 May 2024 10:54:46 GMT

Pragmatism, philosophically, is generally the practical or empirical approach to problems rather than being wedded to some overarching theory. It was a direct response to idealism which maintained that things should be explained by an overall theory.

In vet medicine it has been defined as the treatment of disease using the necessary, but minimum, resources of time and money consistent with good animal welfare whilst ensuring a realistic client understanding (cf the idealist best or most successful diagnostic or therapeutic modality for a condition, against which new tests or results and protocols are compared).

"Pragmatism is a philosophical therapy. It helps you stop asking the unhelpful questions" - Rorty

"Never let a passion for the perfect take precedence over pragmatism" - Isaacson

It isn't easy - in fact it is anything but, and far more nuanced than idealist or "gold standard" medicine and surgery. EBVM can be seen to be allied to a more idealist mindset, hence issues with its use in the real world (and its communication via CPD, teaching etc). Outcome measures for most things have little real world applicability, for instance, and >90% of study populations are skewed referral level animals.

Contextualised doesn't really mean anything (it is not generally defined along with philosophical contextualism which is somewhat different) - as nothing exists in isolation.

BVA (buried in an EWAP minutes I think from 2022) endorsed its use as "the principle of pragmatic case management was supported, with the gold standard determined by the animals' best interests".

The problem we have is that it is easy to make a case for these best interests, and they are repeatedly hijacked by ulterior motives of companies, vets, regulators etc.

RE: Contextualised or pragmatic medicine?

Gillian Mostyn — Wed, 08 May 2024 09:39:49 GMT

[quote userid="2675" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine/244514#244514"]So example: heart with murmur, no decompensation - full investigation including bloods, ecg, ultrasound, proBnp to decide if put on pimobendan or not or trial pimobendan for a month and observe if any improvement or no treatment until heart actually showing decompensation- massive difference, same outcome [/quote]

This a poor example - MVD trials have shown a much better outcome when using pimobendan earlier than just when the dog is symptommatic. Only early investigation (although, granted, not just blindly running every test known to man) can tell you when that point is.

RE: Contextualised or pragmatic medicine?

Richard Carter — Wed, 08 May 2024 08:47:02 GMT

The issue is- some of it ego ( I’ve got all this knowledge/ qualifications etc) and some defensive and some because ‘it’s what the client/ my boss/ the RCVS/ the vds’ wants and some of it is want to get paid / keep my job this month

So example: heart with murmur, no decompensation - full investigation including bloods, ecg, ultrasound, proBnp to decide if put on pimobendan or not or trial pimobendan for a month and observe if any improvement or no treatment until heart actually showing decompensation- massive difference, same outcome

RE: Contextualised or pragmatic medicine?

Beats — Wed, 08 May 2024 07:26:25 GMT

It means something different, but for variety throwing "traditional" into the mix. Point being that a recurrent theme here is harking back to a time when things are considered to have been different (recurring comments such as "pragmatic medicine" is just a new phrase for what we have always done etc).

Negative connotations of "traditional" would include that it sounds like it harks back to a pre-scientific era (such as Traditional Chinese Medicine).

RE: Contextualised or pragmatic medicine?

Cinzia Gandini — Tue, 07 May 2024 22:20:32 GMT

[quote userid="2100" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine"]

The issue here is money. It needs to be tackled head on, and talked about in plain english.

What do you think? Do you agree? Or not?

[/quote]

yes sure, we should stop following the human medicine and start thinking vet

RE: Contextualised or pragmatic medicine?

Cinzia Gandini — Tue, 07 May 2024 22:02:37 GMT

[quote userid="2100" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine"]Then I got a call from someone saying it is better to talk about 'contextualised care', rather than pragmatic medicine, because it removes the judgement associated with offering a lesser service.[/quote]

They are all derived from the human medicine approach, where it seems that the contextualizing care is part of the pragmatic medicine, there's also the Minimally disruptive medicine (MDM) as a patient-centered approach that focuses on achieving patient goals. For me it's all part of a whole, not selling a cheap option but bending the medicine towards the patient rather than the pathology, offering the best approach tailored to that particular patient with that particular disease, avoiding useless procedures and tests that can have an undesirable outcome

RE: Contextualised or pragmatic medicine?

Ben Walker — Tue, 07 May 2024 20:09:41 GMT

[quote userid="2100" url="~/f/non-clinical-questions/30946/contextualised-or-pragmatic-medicine"]The issue here is money. It needs to be tackled head on, and talked about in plain english.[/quote]

As cairncross says, I think “affordable” is the word you’re looking for.

Pragmatic seems to be saying something similar to contextual. Focus on the client in front of you and what they want and can manage. Neither carries negative connotations to me.

Contextual care isn’t about being cheap and I don’t see why “pragmatic” would be either. Budget is just one of many priorities. I’ve said it elsewhere but I think some groups are dodging serious reflection on our business models when they put these forward as a solution, and fiddling with the terminology doesn’t change that.

RE: Contextualised or pragmatic medicine?

cairncross — Tue, 07 May 2024 19:51:45 GMT

Pragmatic seems well defined where the problem is is also very defined lack of affordable care access for the masses