Assessment of companion animal quality of life in veterinary practice and research

Quality of life assessment in dogs and cats receiving chemotherapy - a review of current methods

This study aimed to review currently reported methods of assessing the effects of chemotherapy on the quality of life (QoL) of canine and feline patients and to explore novel ways to assess QoL in such patients in the light of the experience to date in human pediatric oncology. A qualitative comparative analysis of published papers on the effects of chemotherapy on QoL in dogs and cats were conducted. This was supplemented with a comparison of the parameters and domains used in veterinary QoL-assessments with those used in the Pediatric Quality of Life Inventory (PedsQL^™ ) questionnaire designed to assess QoL in toddlers. Each of the identified publications including QoL-assessment in dogs and cats receiving chemotherapy applied a different method of QoL-assessment. In addition, the veterinary QoL-assessments were mainly focused on physical clinical parameters, whereas the emotional (6/11), social (4/11) and role (4/11) domains were less represented. QoL-assessment of cats and dogs receiving chemotherapy is in its infancy. The most commonly reported method to assess QoL was questionnaire based and mostly included physical and clinical parameters. Standardizing and including a complete range of potentially relevant parameters in future QoL assessments may benefit owner decision making.

Psychometric Validation of a General Health Quality of Life Tool for Cats Used to Compare Healthy Cats and Cats with Chronic Kidney Disease

Background

Numerous validated psychometric tools are available to assess impact of disease on a human's quality of life (QoL). To date, no psychometrically validated general health‐related QoL tool exists for cats.

Hypothesis/Objectives

To develop and validate a tool for assessment of owner‐perceived QoL in cats (CatQoL) and to use this tool to compare QoL between healthy cats and those with chronic kidney disease (CKD).

Animals/Subjects

Total of 204 owners of young healthy cats (YH, n = 99; <9 years), older healthy cats (OH, n = 35), and cats diagnosed with CKD (CKD, n = 70) completed the CatQoL.

Methods

Discussions with a focus group and 2 pilot surveys informed design of 16 QoL questions grouped into 4 domains. Each item scored according to frequency and importance, and item‐weighted‐impact‐scores were calculated. The validity of the tool was assessed using principal components analysis and Cronbach's α. The average item‐weighted‐impact‐score (AWIS) was compared among groups and domains.

Results

Sixteen‐item CatQoL showed good internal consistency reliability (Cronbach's α, 0.77) and unidimensionality with significant loadings (0.2–0.7) and communalities (>0.3). Young healthy cats had significantly higher AWIS (median [IQR], 1.25 [0.63, 1.88]) than OH (0.56 [−0.06, 1.00]) and CKD cats (−0.06 [−0.81, 0.88]), P < .001). CKD cats had significantly lower AWIS for eating domain (YH: 2.00 [1.00, 3.00]; OH: 2.00 [0.67, 3.00]; CKD : 1.00 [0.00, 2.67]) when compared with the YH group and OH group, and all groups differed significantly in their management domain (YH: −0.50 [−1.00, 0.00]; OH: −1.00 [−1.88, −0.50]; CKD : −1.50 [−2.50, −1.00], P < .001).

Conclusions and Clinical Importance

The CatQoL was validated for use in cats, and can be used as additional assessment parameter in clinical and research settings.

Ethical principles for novel therapies in veterinary practice

OBJECTIVES

To present insights to aid decision-making about novel veterinary treatments from regulations concerning animal experimentation and human clinical medical trials.

MATERIALS AND METHODS

EU Directive 2010/63/EU on the protection of animals used for scientific purposes and EU Regulation 536/2014 on clinical trials on medicinal products for human use were analysed, evaluated and "translated" into relevant principles for veterinary surgeons.

RESULTS

A number of principles are relevant, relating to treatment expectations, thresholds and objectives; client consent; minimising harms; personnel; review committees; assessment and publication.

CLINICAL SIGNIFICANCE

These principles should assist veterinary surgeons to make good ethical decisions about novel treatments.

Quality of life assessment in domestic dogs: An evidence-based rapid review

Assessment of quality of life (QoL) is an important, increasingly popular outcome measure in veterinary research and practice, particularly in dogs. In humans, QoL is commonly assessed by self-reporting and since this is not possible for animals, it is crucial that instruments designed to measure QoL are tested for reliability and validity. Using a systematic, replicable literature search strategy, the aim of this study was to find published, peer-reviewed instruments for QoL assessment in dogs and to assess the quality of these. CAB Abstracts and PubMed were searched in July 2013 using terms relevant to dogs, wellbeing and QoL. Inclusion and exclusion criteria were applied. When instruments were not published in full, authors were contacted to obtain them. Criteria were applied to assess the quality, validity and reliability of the 52 instruments obtained. Twenty-seven additional instruments used in peer-reviewed publications were not included because they had not been fully described in the publication or were not provided by authors upon request. Most of the instruments reviewed (48/52) were disease-specific rather than generic. Only four publications provided a definition of QoL or wellbeing. Only 11/52 instruments demonstrated evidence of assessing reliability or validity, and the quality of these instruments was variable. Many novel, unvalidated instruments have been generated and applied as clinical outcomes before it was known whether they measured QoL. This rapid review can be used to identify currently available and validated canine QoL instruments, and to assess the validity and quality of new or existing instruments.

Assessment of quality of life in veterinary practice: developing tools for companion animal carers and veterinarians

Quality-of-life assessments aim to provide an all-encompassing evaluation of animal welfare. In comparison to more limited, disease-focused welfare assessments, they have the potential to better identify welfare deficiencies, allowing veterinarians to target improvement strategies for greater benefit. Individuals or populations of companion animals may be assessed and carers and/or veterinarians may contribute to the assessment. Quality-of-life assessments are widely used within the human health care setting, and although the number of veterinary assessment tools is substantially fewer, these tools cover a range of methodologies. Further research to validate existing tools and develop new ones is recommended. Guidance for implementing and evaluating the usefulness of quality-of-life assessment tools within companion animal veterinary clinics is presented.

Establishing 'quality of life' parameters using behavioural guidelines for humane euthanasia of captive non-human primates

Chronic pain and distress are universally accepted conditions that may adversely affect an animal's quality of life (QOL) and lead to the humane euthanasia of an animal. At most research institutions and zoological parks in the USA, a veterinarian, who has physically examined the animal and reviewed the clinical records, ultimately decides when an animal has reached a humane endpoint. To aid in the difficult process of interpreting pain and distress, we have developed specific behavioural guidelines, in addition to standard clinical information, to help define unique characteristics and traits of primates to assess and promote discussion of an individual primate's QOL, and thereby, to assist in the decision-making process regarding euthanasia. These guidelines advocate the creation of a QOL team when the animal is diagnosed with a life-threatening or debilitating chronic condition, or at the time the animal is entered into a terminal study. The team compiles a list of characteristics unique to that individual animal by utilising a questionnaire and a behavioural ethogram. This list enables the team to quantitatively assess any deviations from the established normal behavioural repertoire of that individual. Concurrently, the QOL team determines the number of behavioural deviations that are needed to trigger an immediate discussion of the necessity for humane euthanasia of the animal. The team remains intact once created, and revisits the animal's condition as frequently as deemed necessary. This process improves animal welfare by continuing the quest to optimally define QOL for captive primates, and potentially for all captive animals.

Development, validation and reliability of a web-based questionnaire to measure health-related quality of life in dogs

OBJECTIVES

To describe the development, preliminary validation and reliability testing of a shortened web-based form of GUVQuest, a structured questionnaire to measure health-related quality of life in dogs.

METHODS

The original 109 items were reduced using expert judgement and factor analysis. Validity was established by factor analysis and in a subsequent field trial using a "known groups" approach and classical test theory. Test-retest reliability was assessed using intraclass correlation coefficients.

RESULTS

The instrument comprises 46 items each of which is rated by dog owners using a 7-point Likert scale. Factor analysis revealed a sensible structure containing four health-related quality of life domains (vitality, pain, distress and anxiety) accounting for 64·1% of the variability in the data. The field test involving 125 dogs demonstrated very good discriminative properties and intraclass correlation coefficient values of greater than 0·6.

CLINICAL SIGNIFICANCE

This is the first report of a valid and reliable companion animal health-related quality of life instrument, the contemporary approach to animal welfare measurement, which is presented in a web-based format, with automated production of a health-related quality of life profile. It offers major advantages to dog owners, practitioners and researchers.

Questionnaire-based assessment of owner concerns and doctor responsiveness: 107 canine chemotherapy patients

OBJECTIVE

To quantify owner concerns regarding clinical signs in canine patients receiving chemotherapy and to assess degree of concordance between client and veterinarian concerns regarding patient quality of life.

METHODS

Retrospective analysis of owner-reported concerns during chemotherapy treatment. Owner-reported adverse events were recorded sequentially for each patient through a partially open design questionnaire and correlated with veterinary patient summaries for each visit. Canine patients treated for transitional cell carcinoma, haemangiosarcoma, malignant melanoma or osteosarcoma were eligible for inclusion. Minimum treatment eligibility was two chemotherapy treatments given in 21-day protocol cycles, with a maximum of six treatment cycles recorded.

RESULTS

A total of 553 evaluable visits, seen by 18 oncology clinicians, were assessed. Owners expressed concern before chemotherapy in 48% of visits. Owner concerns at the first visit did not differ significantly from those expressed at the sixth visit. Remission status was a significant factor in owners' rate of reporting concerns. Diarrhoea grade was associated with owners' concerns. Clinician gender was not associated with responsiveness to owners' concerns.

CLINICAL SIGNIFICANCE

Questionnaire-based surveys appear to be an effective tool for communicating dog owners' concerns regarding chemotherapy and potentially for monitoring a clinician's attentiveness. Owners expressed concerns at approximately half of chemotherapy appointments.

Evaluation of a quality-of-life tool for dogs with diabetes mellitus

BACKGROUND

Diabetes mellitus (DM) management primarily focuses on improvement in blood glucose concentrations and clinical signs. A tool to assess the psychological and social impact of DM and its treatment on quality of life (QoL) previously has only been validated for feline DM.

HYPOTHESIS/OBJECTIVES

To validate a diabetic pet and owner-centered individualized measure of impact of DM (DIAQoL-pet) for diabetic dogs and their owners. ANIMALS/SUBJECTS: A total of 101 owners of insulin-treated diabetic dogs were recruited to complete the DIAQoL-pet.

METHODS

Discussions and pilot surveys with clinicians and owners of diabetic pets led to the design of 29 specific DM-associated QoL questions. Each item was scored according to impact frequency and perceived importance. An Item-Weighted-Impact-Score (IWIS) for each item was calculated, as was an Average-Weighted-Impact-Score (AWIS) by averaging all IWISs. Principal component analysis and Cronbach's α calculation assessed the measure's reliability.

RESULTS

The DIAQoL-pet showed high reliability (Communalities ≥0.5; Cronbach's α 0.85). The AWIS was -2.74 ± 1.7 (mean ± SD). Areas reported as most negatively impacting QoL included: "worry" (IWIS ± SD: -5.92 ± 4.3), "difficulties leaving dog with friends or family" (-5.68 ± 5.1), "worry vision" (-5.58 ± 4.6), "boarding difficulties" (-5.18 ± 5.2), "worry hypoglycemia" (-4.95 ± 4.3), "social life" (-4.82 ± 4.4), "costs" (-4.11 ± 4.7), and "future care"(-4.07 ± 4.6). Eighty-four percent of owners reported negative impact of DM on QoL.

CONCLUSIONS AND CLINICAL IMPORTANCE

The DIAQoL-pet proved robust when used by owners of insulin-treated diabetic dogs and identified specific areas most negatively impacting dogs' and their owners' QoL. This tool could be used as an additional assessment parameter in clinical and research settings.

Promoting discussions and decisions about dogs' quality-of-life

OBJECTIVE

The objective of this paper is to report the formulation and preliminary testing of a participatory tool in order to encourage discussions and decisions about dogs' quality-of-life.

MATERIALS AND METHODS

A tool was designed in which owners rated aspects of their dog's quality-of-life. Two randomised controlled trials were conducted: one with a veterinary surgeon who was involved in the tool design, the second with other veterinary surgeons. In each, owners either were given the tool before a veterinary consultation or underwent normal consultations. After each consultation, owners were asked to report what they had discussed and what decisions they had made.

RESULTS

The study involved a total of 170 consultations, of which 91 were randomly allocated to the tool group and 79 into the control group. In both trials, using the tool was associated with a significant increase in the frequency of discussions. In the first trial, using the tool was also associated with an increase in the number of decisions made, but this was not found in the second trial with practitioners who were not involved in the trial design.

CLINICAL SIGNIFICANCE

These data suggest that the use of a participatory tool has the potential to enhance the effectiveness of consultations, especially if the practitioner is familiar with the tool design.

Maximising canine welfare in veterinary practice and research: a review

This article looks at the existing evidence-base by which veterinary surgeons can make welfare-focused treatment choices. Narrative and structured reviews were conducted. Papers were categorised under headings based on (1) themes in the UK Animal Welfare Act (AWA 2006) - behaviour, environment, nutrition, company and health; (2) iatrogenic harm induced by treatment; (3) decision-making methods, and (4) the subjects' context (e.g. home versus laboratory). There is more information available about 'overt' problems (e.g. acute disease), than 'covert' issues (e.g. chronic pain, lack of company and obesity). Forty of 109 papers covered pain, suffering, injury and disease, compared to 69 across four other themes in the AWA. Twelve papers were identified as focusing on welfare assessment and clinical decision-making. Veterinary surgeons should consider each of the five welfare themes described in the AWA in both veterinary practice and in determining veterinary research priorities.

Owners’ perceptions of quality of life in geriatric horses: a cross-sectional study

Quality of life (QoL) is increasingly recognised as a more important measure of treatment success than prolongation of life. Assessment of QoL may aid decision-making for treatment or euthanasia. This study aimed to evaluate owners’ perceptions of factors affecting their horse's QoL and those factors that may contribute to their decision-making process for treatment or euthanasia of geriatric horses. A cross-sectional study was conducted, surveying a randomly selected sample of veterinary registered owners (n = 1,144) with horses aged ≥ 15 years, using a self-administered postal questionnaire. A section of this questionnaire contained 16 mixed-mode questions about the horse's QoL and factors influencing decisions on treatment. Horses from the cross-sectional survey were enrolled in a longitudinal study and, for cases of euthanasia, a further telephone questionnaire was completed to investigate factors influencing the owner's decision. Owners reported that the majority of geriatric animals enjoyed a high QoL, with 95% of owners rating their horse's QoL as good or excellent on an average day. However, increasing age corresponded negatively with many of the health-related QoL factors. Owners considered long-term diseases that cause chronic pain to affect their animal's QoL more than a disease causing a single episode of acute pain. The most important factors influencing choice of treatment options for a severe illness or injury were QoL after procedure, life-threatening disorders, painful/stressful procedures and veterinary advice. In conclusion, owner ratings and perceptions of factors affecting QoL of geriatric horses may prove useful in the development of a QoL assessment tool for ageing horses.

Is welfare all that matters? A discussion of what should be included in policy-making regarding animals

Policy-making concerned with animals often includes human interests, such as economy, trade, environmental protection, disease control, species conservation etc. When it comes to the interests of the animals, such policy-making often makes use of the results of animal welfare science to provide assessments of ethically relevant concerns for animals. This has provided a scientific rigour that has helped to overcome controversies and allowed debates to move forward according to generally agreed methodologies. However, this focus can lead to policies leaving out other important issues relevant to animals. This can be considered as a problem of what is included in welfare science, or of what is included in policy. This suggests two possible solutions: expanding animal welfare science to address all ethical concerns about animals’ interests or widening the perspective considered in policymaking to encompass other important ethical concerns about animals than welfare. The latter appears the better option. This requires both a ‘philosophy of animal welfare science’, a ‘philosophy of decision-making about animals’, and greater transparency about what is included or excluded from both animal welfare science and the politics of animal policy.

Is ‘a life worth living’ a concept worth having?

A recent FAWC report introduced ‘a life worth living’ as a useful concept in farm animal welfare discussions and policy. But what does this concept mean? And is it a useful one? This paper extends FAWC's approach in several ways. It firstly provides an account of the concept of a life worth living in more detail, in relation to current animal welfare thinking, such as experiences and quality of life. It then describes how the concept might be applied in animal welfare management decisions and in setting standards for regulations and Farm Assurance schemes. The paper identifies several advantages to the concept: it is animal-based, intuitively understandable, and has direct prescriptive force in decision-making. But the concept also has certain limitations, especially that it is potentially complex and subjective and that it cannot include all ethically relevant concerns about farm animal welfare. Nevertheless, the paper concludes that the concept may become a useful addition to welfare dialogue, and finishes by identifying the core areas where further work is necessary.

Assessment of quality of life in equine patients

REASONS FOR PERFORMING STUDY

Assessing patients' quality of life (QOL) is a core part of clinical decision making. Various methodologies for assessing patients' QOL have been developed in human medicine and small animal veterinary disciplines. In contrast, the lack of aids for QOL assessment in equine veterinary practice leaves practitioners reliant on subjective assessments of QOL, which may be prone to avoidable errors.

OBJECTIVES

This paper suggests pragmatic ways in which QOL may be enhanced, while remaining appropriate for the time, financial and owner-based constraints within equine practice.

METHODS

Through interdisciplinary research, this paper identifies, adapts and applies insights from several areas of research and practical experience in order to develop an overarching approach to making QOL-based decisions in clinical cases.

RESULTS

The paper identifies 6 steps involved in QOL-based decision making and provides examples of how these steps may be practically applied. These include deciding what each clinician feels is important; deciding how to evaluate it, including taking owners' views into consideration; making decisions about each case and achieving the desired clinical outcomes.

CONCLUSIONS

Practitioners can draw their own conclusions on how they may improve QOL assessment in practice and may usefully share these with colleagues. Reporting cases and sharing practical examples of QOL tools used on the ground are vital to the development of this field and appropriate methodologies.

POTENTIAL RELEVANCE

Improvements in QOL assessment are relevant to all areas of equine veterinary practice, and several areas of research. Further research may develop QOL assessment in practice, but more important are the personal improvements that each practitioner may achieve.

WSAVA nutritional assessment guidelines

OBJECTIVES

Careful assessment of the nutritional needs of cats and dogs must be taken into consideration in order to maintain optimum health, be part of a treatment regimen for a diseased state, or to maximize the quality of life in all animals. The goal of these World Small Animal Veterinary Association (WSAVA) Guidelines is that a nutritional assessment and specific nutritional recommendation is made for every patient on every visit. This will become known as the 5th Vital Assessment (5VA), following the four vital assessments of temperature, pulse, respiration and pain that are already addressed on each patient interaction.

EVALUATION OF NUTRITIONAL STATUS

A brief screening evaluation of nutritional status can be routinely and seamlessly performed during the history-taking and physical examination of every patient. Nutrition-related risk factors that can be easily identified from the history and physical examination include age (growing or old), suboptimal body condition score (overweight or thin), muscle loss, atypical or homemade diet, medical conditions or changes in appetite. An extended evaluation would follow if one or more risk factors is identified on screening. These guidelines provide criteria with which to evaluate the animal and the diet, as well as key feeding and environmental factors. In addition, recommendations for interpretation, analysis and action are included so that a plan for optimizing the animal's nutritional status can be instituted.

TEAM APPROACH

Client compliance with nutritional recommendations requires input from the veterinarian, veterinary technicians/nurses and hospital staff. A team approach to continuous nutritional education, implementation of appropriate protocols, and focused client communication, utilizing these WSAVA Nutritional Assessment Guidelines, is key to reaching this 5VA goal.

Comparison of owner-reported health problems with veterinary assessment of geriatric horses in the United Kingdom

REASONS FOR PERFORMING STUDY

Previous studies suggest that owners underestimate or incorrectly recognise or report health problems in geriatric horses. However, few studies have directly compared owner-reported and veterinary assessed disease.

OBJECTIVES

To compare the findings of veterinary clinical examination of geriatric horses with owner-reported clinical signs and disease.

METHODS

A total of 200 horses aged ≥ 15 years were randomly selected to receive a veterinary examination, from responses to a cross-sectional postal questionnaire survey. Veterinary examinations were performed within 2 months of questionnaire return, and agreement between owner-reported data and veterinary clinical findings was assessed.

RESULTS

Owners under-reported many clinical signs and disease conditions detected on veterinary clinical examination. For example, dental abnormalities (detected in 95.4% of horses, reported by 24.5% of owners); cardiac murmurs (detected in 20% of horses, reported by 0.5% of owners); lameness (present in 50% of horses, reported by 23% of owners) and hoof abnormalities (detected in 80% of horses, reported by 27% of owners). Agreement between owner-reported and veterinary assessed respiratory disease (Kappa 0.02-0.2), body condition score (Kappa 0.24) and coat abnormalities (Kappa 0.42) was poor, fair and moderate, respectively. Range of motion (ROM) of the tarsal and metacarpophalangeal joints was lower in horses with owner-reported osteoarthritis (P = 0.005 and <0.001, respectively).

CONCLUSIONS AND POTENTIAL RELEVANCE

The low prevalence and relatively poor agreement of owner-reported disease compared to that detected on veterinary examination suggests inaccurate or under-recognition, or inaccurate reporting of health problems by owners of geriatric horses, which could lead to a delay in presentation for veterinary treatment. Increased veterinary involvement and improved owner education in the care of geriatric horses should facilitate earlier identification of disease, particularly that which is not readily detectable by owners, and aid management of health and welfare problems.

Quality of life of dogs with skin diseases and their owners. Part 1: development and validation of a questionnaire

The aim of this study was to develop and evaluate a questionnaire on the quality of life (QoL) of dogs with skin diseases and their owners. Twenty-six qualitative interviews with owners of dogs affected with severe skin diseases were performed to identify which aspects of the life of dogs and owners were impaired. To assess the clarity of questions, a preliminary 19-item questionnaire (answer range, 0 = none to 3 = severe) was developed following current models from human dermatology and administered to a pilot sample of 20 owners. Questions with a low positive answering rate or statistical relevance were eliminated. A final 15-item questionnaire was distributed to the owners of 41 dogs with atopic dermatitis (AD) and 40 healthy dogs. The severity of the AD was assessed by an owners' severity scale (0-3), a descriptive Visual Analogue Scale for pruritus and CADESI-03. The correlation between these results and those of the questionnaire were analysed. Repeatability was evaluated by testing 44 owners of dogs with different skin diseases on two occasions 3 days apart. The QoL scores for dogs with AD and their owners were significantly different from those for healthy control dogs (P = 0.0001). There was a reliable repeatability of scores (α = 0.8). Owner-perceived severity correlated significantly with QoL scores (P = 0.02). The correlation between QoL and pruritus scores was high (>0.36), while that with CADESI-03 was lower (<0.26).

Development of a questionnaire assessing health-related quality-of-life in dogs and cats with cancer

Health-related quality-of-life (HRQoL) has been studied extensively in human medicine. There is currently no standard HRQoL evaluation for veterinary oncology patients. The aim of this study was to assess the practicality, usefulness and robustness, from a pet owner and clinician perspective, of a questionnaire for the assessment of HRQoL in canine and feline cancer patients. A HRQoL assessment entitled 'Cancer Treatment Form' and two questionnaires entitled 'Owner Minitest' and 'Clinician Minitest' were designed. The first and second were completed by owners of patients presenting to a veterinary oncology referral service and the third by attending clinicians. The 'Cancer Treatment Form' was well received by owners and clinicians and provided a valuable assessment of HRQoL with 98% (82/84) of owners reporting an accurate reflection of their pet's quality-of-life. Following this, minor improvements to the form could be suggested prior to regular use in evaluation of clinical oncology patients.

Breeding for pleasure: the value of pleasure and pain in evolution and animal welfare

Farming and laboratory industries face questions about whether to breed animals with altered capacities for pleasure and pain. This paper addresses this issue from different approaches to animal welfare based on experiences, fitness and naturalness. This can illuminate both the breeding-related issues and the different approaches themselves. These differences have practical implications for decisions about animal breeding. All three approaches will agree that pleasure that is adaptive in natural environments has positive value and that maladaptive pain has negative value. However, where animals’ environments will not be natural, experiences-based approaches may support breeding animals that experience more pleasure and less pain or insentient animals; whereas, in some cases, fitness-based and naturalness-based approaches might favour the breeding of animals that experience more pain and less pleasure.