Shortening of an existing generic online health-related quality of life instrument for dogs

Inflammation and Behavior Changes in Dogs and Cats

Sickness is a normal response to infections or stress triggered by proinflammatory cytokines that drive local and systemic inflammatory responses. Proinflammatory cytokines act on the brain causing the so called "sickness behavior,"which is thought to improve recovery but can become maladaptive in the long term. Chronic inflammation characterizes many diseases and there is some evidence that dogs and cats experience age-associated increases in inflammation, a condition named "inflammaging." A complex and multifactorial relationship exists between these inflammatory mechanisms, pain, and psychological illness that may complicate veterinary diagnosis and affect the outcome.

Development and Validation of a Canine Health-Related Quality of Life Questionnaire and a Human-Canine Bond Questionnaire for Use in Veterinary Practice

The use of valid questionnaires to assess dogs' health-related quality of life (HRQoL) in veterinary practice can improve canine health outcomes and communications between veterinarians and caretakers of dogs. The Canine HRQoL Questionnaire (Canine HRQoL-Q) and the Human-Canine Bond Questionnaire (HCBQ) were developed and validated to fulfill this need. A literature review, interviews with veterinarians, and focus groups with caretakers were conducted to generate questionnaire items and develop draft questionnaires, which were piloted with caretakers to establish their content validity. Measurement properties were evaluated using data from a prospective survey study (N = 327). Draft Canine HRQoL-Q and HCBQ measures were developed, including a domain structure, items, recall period, and scale/response options. Refinements were made via iterative cognitive interviews with caretakers. When no additional revisions were indicated and content validity was established, the questionnaires were psychometrically tested. Ceiling effects were observed for all items, and factor analyses indicated that the pre-specified domains are appropriate. Internal consistency was demonstrated for the HCBQ (α = 0.79-0.86) and all but the social functioning domain of the Canine HRQoL-Q (α = 0.60). Test-retest reliability for the Canine HRQoL-Q was generally moderate-to-good (with intraclass correlation coefficients (ICCs) > 0.79). Test-retest reliability for the HCBQ was moderate (ICCs: 0.70-0.79) except for the trust domain (ICC: 0.58). Known-groups validity was demonstrated via significant differences (p < 0.05) in scores for health/bonding groups. Convergent validity was supported (r > 0.40) between all domains and the total scores for both questionnaires. The Canine HRQoL-Q and the HCBQ are valid, reliable measures of canine HRQoL for use in veterinary clinics and appear to measure related but distinct concepts that contribute to canine health and wellness.

Evaluating instruments for assessing healthspan: a multi-center cross-sectional study on health-related quality of life (HRQL) and frailty in the companion dog

Developing valid tools that assess key determinants of canine healthspan such as frailty and health-related quality of life (HRQL) is essential to characterizing and understanding aging in dogs. Additionally, because the companion dog is an excellent translational model for humans, such tools can be applied to evaluate gerotherapeutics and investigate mechanisms underlying longevity in both dogs and humans. In this multi-center, cross-sectional study, we investigated the use of a clinical questionnaire (Canine Frailty Index; CFI; Banzato et al., 2019) to assess frailty and an owner assessment tool (VetMetrica HRQL) to evaluate HRQL in 451 adult companion dogs. Results demonstrated validity of the tools by confirming expectations that frailty score increases and HRQL scores deteriorate with age. CFI scores were significantly higher (higher frailty) and HRQL scores significantly lower (worse HRQL) in old dogs (≥ 7 years of age) compared to young dogs (≥ 2 and < 6 years of age). Body size (small < 11.3 kg (25 lbs) or large > 22.7 kg (50 lbs)) was not associated with CFI or total HRQL score. However, older, larger dogs showed faster age-related decline in HRQL scores specific to owner-reported activity and comfort. Findings suggest that the clinician-assessed CFI and owner-reported VetMetrica HRQL are useful tools to evaluate two determinants of healthspan in dogs: the accumulation of frailty and the progressive decline in quality of life. Establishing tools that operationalize the assessment of canine healthspan is critical for the advancement of geroscience and the development of gerotherapeutics that benefit both human and veterinary medicine. Graphical summary of the design, results, and conclusions of the study.

Efficacy of autologous mesenchymal stromal cell treatment for chronic degenerative musculoskeletal conditions in dogs: A retrospective study

Introduction

The objective of this study was to retrospectively analyze clinical data from a referral regenerative medicine practice, to investigate the efficacy of autologous mesenchymal stromal cells (MSC) in 245 dogs deemed unresponsive to conventional treatment by their referring vet.

Methods

Diagnostic imaging [radiology and musculoskeletal ultrasound (MSK-US)] identified musculoskeletal pathology holistically. MSCs, produced according to current guidelines, were initially administered with PRP by targeted injection to joints and/or tendons, with a second MSC monotherapy administered 12 weeks later to dogs with severe pathology and/or previous elbow arthroscopic interventions. Dogs with lumbosacral disease received epidural MSCs with additional intravenous MSCs administered to dogs with spondylosis of the cervical, thoracic and lumbar spine. All dogs received laser therapy at 10 J/cm² at the time of treatment and for 5 sessions thereafter. Objective outcome measures (stance analysis, range of joint motion, pressure algometry) and validated subjective outcome measures (owner reported VetMetrica HRQL™ and veterinary pain and quality of life impact scores) were used to investigate short and long-term (6-104 weeks) efficacy. Outcome data were collected at predetermined time windows (0-6, 7-12, 13-18, 19-24, 25-48, 49-78, 79-104) weeks after initial treatment.

Results

There were statistically significant improvements in post compared with pre-treatment measures at all time windows in stance analysis, shoulder and hip range of motion, lumbosacral pressure algometry, and to 49-78 weeks in carpus and elbow range of motion. Improvements in 4 domains of quality of life as measured by VetMetricaTM were statistically significant, as were scores in vet-assessed pain and quality of life impact. In dogs receiving one initial treatment the mean time before a second treatment was required to maintain improvements in objective measures was 451 days. Diagnostic imaging confirmed the regenerative effects of MSCs in tendinopathies by demonstrating resolution of abnormal mineralization and restoration of normal fiber patterns.

Discussion

This represents the first study using "real-world" data to show that cell-based therapies, injected into multiple areas of musculoskeletal pathology in a targeted holistic approach, resulted in rapid and profound positive effects on the patient's pain state and quality of life which was maintained with repeat treatment for up to 2 years.

Development and initial validation of a dog quality of life instrument

The increasing attention for the dog-owner relationship combined with advances in nutrition and veterinary care have made wellbeing a focal point for dog owners, veterinarians, and dog product and service providers. While canine wellbeing can be quantified by survey-based quality of life instruments like those used in human healthcare, there are currently few instruments available that can do this reliably and at scale. Here we report the development and initial validation of a canine quality of life instrument specifically designed to quantify wellbeing in the general dog population. The instrument is based on a simple 32-question survey and includes 5 daytime domains (energetic, mobile, relaxed, happy, sociable) and 3 mealtime domains (relaxed, interested and satisfied). It captures specific health-related aspects as well as more general wellbeing aspects and, in an initial sample of 2813 dogs, already provides useful insights on canine wellbeing. We believe that data collection at scale with this instrument will help bring optimal wellbeing to the dogs we care for.

Canine Geriatric Syndrome: A Framework for Advancing Research in Veterinary Geroscience

Biological aging is the single most important risk factor for disease, disability, and ultimately death in geriatric dogs. The effects of aging in companion dogs also impose significant financial and psychological burdens on their human caregivers. The underlying physiologic processes of canine aging may be occult, or early signs of aging may be ignored because of the misconception that biological aging is natural and therefore inevitable. The ability to detect, quantify, and mitigate the deleterious processes of canine aging would greatly enhance veterinary preventative medicine and animal welfare. In this paper we propose a new conceptual framework for aging in dogs, the Canine Geriatric Syndrome (CGS). CGS consists of the multiple, interrelated physical, functional, behavioral, and metabolic changes that characterize canine aging as well as the resulting clinical manifestations, including frailty, diminished quality of life, and age-associated disease. We also identify potential key components of a CGS assessment tool, a clinical instrument that would enable veterinarians to diagnose CGS and would facilitate the development and testing of interventions to prolong healthspan and lifespan in dogs by directly targeting the biological mechanisms of aging. There are many gaps in our knowledge of the mechanisms and phenotype of aging in dogs that must be bridged before a CGS assessment tool can be deployed. The conceptual framework of CGS should facilitate identifying these gaps and should stimulate research to better characterize the processes and effects of aging in dogs and to identify the most promising preventative strategies to target these.

Evidence-based evaluation of owner-reported outcome measures for canine orthopedic care - a COSMIN evaluation of 6 instruments

OBJECTIVE

To systematically review the currently available validated owner-reported outcome measures (OROMs) for assessing pain and function in dogs with osteoarthritis and other joint diseases.

STUDY DESIGN

Systematic review.

METHODS

A systematic literature search of PubMed and Web of Science was performed in December, 2019, using search terms relevant to OROMs for pain and function in dogs with osteoarthritis and other joint diseases. The measurement properties of the resulting outcome instruments and validation studies were evaluated with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN).

RESULTS

Seventeen publications describing the validation of 6 OROMs were selected and evaluated with the COSMIN. The Canine Brief Pain Inventory (CBPI), Canine Orthopedic Index (COI), and Liverpool Osteoarthritis in Dogs (LOAD) provided evidence of sufficient content validity. Internal consistency, reliability, construct validity, and responsiveness were the most frequently validated other properties. Both CBPI and COI had sufficient internal consistency; LOAD, being formative in construct, need not be assessed for internal consistency. No instruments provided information on measurement errors.

CONCLUSION

The CBPI, COI, and LOAD can be recommended for use in dogs with osteoarthritis. Further evidence is necessary to increase the interpretability of these instruments or expand their application into other canine orthopedic conditions. Further evidence is also needed before the other 3 instruments can be recommended.

CLINICAL SIGNIFICANCE

This systematic evaluation of 6 OROMs provides clinicians and researchers with a tool that facilitates and improves evidence-based selection of outcome measures for evaluating canine osteoarthritis and other joint disease treatments.

Effect of Age, Breed, and Sex on the Health-Related Quality of Life of Owner Assessed Healthy Dogs

Using an app, this exploratory study generated information on HRQL in a large cohort of dogs deemed healthy according to the owner. It forms the basis for further studies investigating the natural history of HRQL of dogs to inform the interpretation of interventional studies, but highlights the risks of relying on owner impression of health status. A previously published health-related quality of life (HRQL) instrument (VetMetrica™) that generates scores in four domains of quality of life in dogs - Energetic and Enthusiastic (E/E), Happy and Content (H/C), Active and Comfortable (A/C), and Calm and Relaxed (C/R), generated information on HRQL in 4,217 dogs (3 months−21 years). Dogs were categorized by age; young, 3–47 months, middle-aged, 48–95 months, and old, 96 months and older. Owners considered 2,959 dogs (3–95 months) to be “in perfect health” and these were used to explore the relationship between age, sex, breed and HRQL in apparently healthy dogs. Mean score was significantly greater (better) in young compared to middle-aged dogs in E/E, H/C and A/C and declined with advancing age. In H/C there was a small but significant difference in mean score between female and male dogs (mean greater in females), with a similar rate of decline in each gender with advancing age. In E/E there were very small but statistically significant differences in mean scores between certain breeds. In A/C there was a statistically significant interaction between breed and age and the rate of decline with advancing age differed with breed. Overall, age, breed, and sex predicted very little of the variation seen in HRQL scores. Data from a subset of 152 dogs, for whom clinical information was available, were used to examine the agreement between clinical evidence and owner opinion. According to the clinical records, 89 dogs were healthy and 63 had evidence of chronic disease. There was an approximately 40% disagreement between owner opinion on health status and clinical evidence of chronic disease (35% disagreement in all dogs and 43% in old dogs). HRQL scores were generally higher in dogs for whom there was no evidence of disease in the clinical record.

Optimisation of Scores Generated by an Online Feline Health-Related Quality of Life (HRQL) Instrument to Assist the Veterinary User Interpret Its Results

Using methodology previously described for the dog health-related quality of life (HRQL) tool (VetMetrica™), the aim was to optimize the scores profile of a comparable feline online HRQL instrument for monitoring HRQL in cats, to assist in its interpretation. Measuring HRQL helps quantify the impact of disease and its treatment on well-being, aids clinical decision making and provides information in clinical trials. In Study 1, using data collected from previous studies, scores generated for three domains of HRQL (Vitality, Comfort, Emotional Well-being) in healthy cats were normalized using standard statistical techniques of logit transformation and T-scores, such that the average healthy cat has a score of 50 in all three HRQL domains. Using normalized scores from healthy and sick cats, a threshold score of 44.8 was determined, above which 70% of healthy cats should score. Study 2 determined the Minimal Important Difference (MID) in normalized score that constituted a clinically significant improvement in each domain. Three methods were tested in order to determine the MID, with the final choice made based on statistical and clinical considerations. Thresholds of 5, 7.5, and 5 were chosen for the three HRQL domains representing Vitality, Comfort and Emotional Well-being, respectively. This study makes available a means of displaying HRQL scores from an online application in an easily interpretable manner and quantifies a clinically meaningful improvement in score. To illustrate the practical application of these developments, three case examples are presented. Example 1 illustrates the raw and normalized scores for a group of overweight cats enrolled in a Feline Weight Management Programme. Example 2 shows three groups of osteoarthritic cats, each with different severity of disease. The third is an elderly, un-well cat whose HRQL was recorded over time, specifically to facilitate end of life discussion between owner and veterinary clinician.

Development of an Early Warning System for Owners Using a Validated Health-Related Quality of Life (HRQL) Instrument for Companion Animals and Its Use in a Large Cohort of Dogs

Preventive measures in human healthcare are recognized as a means of providing early detection of disease, however, the veterinary profession has not been as effective in communicating the benefits of preventive measures to pet owners. Readily available pet healthcare information on the internet, owners not understanding that regular health evaluations can ensure the well-being of their pets and owners confusing the signs of chronic disease with normal aging have contributed to declining numbers of veterinary visits. The use of web-based generic health–related quality of life (HRQL) measures to evaluate health status (wellness) remotely could facilitate veterinary preventive medicine. This publication describes the development and practical application of an integrated alert system for an online generic HRQL measurement instrument (VetMetrica™) which generates scores in four domains of HRQL—Energetic/Enthusiastic (E/E), Happy/Content (H/C), Active/Comfortable (A/C), and Calm/Relaxed (C/R)—for 2 age groups (young/middle-aged, ≤7 years and old, ≥8 years). The alert provides an early warning, via email to owners, that a potentially significant deterioration in health status has occurred. The model accurately predicted the health status of 93 and 83% of sick young/middle aged and old dogs respectively, with healthy dogs predicted with 83% accuracy. HRQL data, collected via a white-labeled veterinary clinic branded app designed to facilitate connected care between owner and veterinarian, were analyzed for 6,108 dogs, aged between 6 weeks and 16 years. Of these 5,002 were deemed to be in perfect health by their owners, yet the alert was triggered for 1,343 (27%) of these, 75% of which were young/middle-aged and 25% were old, indicating that acute injuries notwithstanding, many middle aged dogs may have been suffering from undetected chronic disease such as osteoarthritis. This work has demonstrated that the use of VetMetrica™ delivered via the PetDialog™ app, which supports 24/7 remote health monitoring is an efficient way for vets to provide all their owners with the opportunity to monitor their animal's wellness throughout their lifetime, providing the vet with a mechanism to identify health problems early while stimulating owners to be more proactive in seeking veterinary attention.

Development and evaluation of a health-related quality-of-life tool for dogs with Cushing's syndrome

Background

Clinical signs and consequences of Cushing's syndrome are likely to impact upon a dog's life. Quantification of this impact on a dog's health‐related quality‐of‐life (HRQoL) could contribute to optimized disease management.

Hypothesis/objectives

To develop a novel HRQoL tool to aid assessment of dogs with Cushing's syndrome and to evaluate factors that impact upon dogs living with this disease.

Animals

Two hundred and ten dogs with Cushing's syndrome and 617 dogs without Cushing's syndrome.

Methods

Cross‐sectional study design. Dog owners answered questions relating to the HRQoL of their dogs which were refined to develop the final tool. The tool was analyzed for reliability, validity, and interpretability, including Cronbach's alpha and principal components analysis. Factors impacting upon the HRQoL of dogs with Cushing's syndrome were assessed using appropriate nonparametric tests.

Results

The tool was refined from 32 questions to 19 and showed good internal consistency (α = .83). Owners rated questions related to “owner impact” as more important and those related to demeanor as less important. There was a positive correlation between the tool score of dogs with Cushing's syndrome and owner's assessment of their dog's quality‐of‐life (r = .41, P < .001). Dogs currently on treatment with trilostane had a statistically better HRQoL (.33, interquartile range [IQR] .23–.44) than those not receiving trilostane (.36, IQR .33–.54, P = .04).

Conclusions and Clinical Importance

The developed tool quantifies the HRQoL of dogs with Cushing's syndrome and could assist clinicians in the clinical assessment of dogs with Cushing's syndrome.

Optimising outputs from a validated online instrument to measure health-related quality of life (HRQL) in dogs

Measurement of health-related quality of life (HRQL) is becoming increasingly valuable within veterinary preventative health care and chronic disease management, as well as in outcomes research. Initial reliability and validation of a 22 item shortened version of VetMetrica (VM), structured questionnaire instrument to measure HRQL in dogs via a mobile application was reported previously. Meaningful interpretation and presentation of the 4 domain scores comprising the HRQL profile generated by VM is key to its successful use in clinical practice and research. Study one describes transformation of domain scores from 0-6 to 0-100 and normalisation of these based on the healthy canine population in two age ranges, such that a score of 50 on a 0-100 scale represents the score for the age-related average healthy dog, and establishment of a threshold to assess domain-specific health status for individual dogs. This provides the clinician with a simple method of ascertaining the health status of an individual dog relative to the average healthy population in the same age group (norm-based scoring). Study two determines the minimum important difference (MID) in domain scores which represents the smallest improvement in score that is meaningful to the dog owner, thus providing the clinician with a means of recognising what is likely to be a significant improvement in scores for an individual dog over time. Visual representation of these guidelines for the purpose of interpreting VM profile scores is presented using case studies.

Pain characterization and response to palliative care in dogs with naturally-occurring appendicular osteosarcoma: An open label clinical trial

This study aimed to characterize bone cancer pain (quantitative sensory testing (QST), stance asymmetry index, actimetry, scores of pain and quality of life (QoL)) in dogs with appendicular osteosarcoma (OSA), and to evaluate a stepwise palliative analgesic treatment.

The pain profile of thirteen client-owned dogs with OSA was compared with seven healthy dogs. Dogs with OSA were then enrolled in a prospective, open-label, clinical trial. Outcome measures included: primary and secondary mechanical thresholds (MT), conditioned pain modulation (CPM), stance asymmetry index, actimetry (most and least active periods), visual analog scales and QoL. After baseline assessments, stepwise treatment comprised orally administered cimicoxib (2 mg/kg q 24h), amitriptyline (1–1.5 mg/kg q 24h) and gabapentin (10 mg/kg q 8h); re-evaluations were performed after 14 (D14), 21 (D21) and 28 (D28) days, respectively. Statistics used mixed linear models (α = 5%; one-sided). Centralized nociceptive sensitivity (primary and secondary MT, and dynamic allodynia) was recorded in OSA dogs. Healthy dogs had responsive CPM, but CPM was deficient in OSA dogs. Construct validity was observed for the QST protocol. Asymmetry index was significantly present in OSA dogs. The CPM improved significantly at D14. When compared with baseline (log mean ± SD: 4.1 ± 0.04), most active actimetry significantly improved at D14 (4.3 ± 0.04), D21 and D28 (4.2 ± 0.04 for both). When compared with baseline, least active actimetry significantly decreased after treatment at all time-points indicating improvement in night-time restlessness. No other significant treatment effect was observed. Except for tactile threshold and actimetry, all outcomes worsened when gabapentin was added to cimicoxib-amitriptyline. Dogs with bone cancer are affected by widespread somatosensory sensitivity characterized by peripheral and central sensitization and have a deficient inhibitory system. This severe pain is mostly refractory to palliative analgesic treatment, and the latter was only detected by specific and sensitive outcomes.

Development, initial validation and reliability testing of a web-based, generic feline health-related quality-of-life instrument

Objectives

The objective of this study was to develop a valid, reliable, web-based generic feline health-related quality-of-life (HRQoL) questionnaire instrument to measure the affective impact of chronic disease.

Methods

A large initial item pool, obtained through interviews with cat owners, was reduced using predetermined criteria, survey scores for relevance and clarity, and the ability of individual items to discriminate between healthy and sick cats when owners completed a prototype questionnaire. Using these data, factor analysis was used to derive a scoring algorithm and provide evidence for factorial validity. Validity was demonstrated further in a field trial using a ‘known groups’ approach (sick vs healthy cats will have a different HRQoL profile, and the HRQoL profile of cats will deteriorate as comorbidities increase). Test–retest reliability was assessed using intra-class correlation coefficients (ICCs).

Results

In total, 165 items were reduced to 20 and, on the basis of a factor analysis that explained 72.3% of the variation in scores input by 71 owners of 30 healthy and 41 sick cats using the prototype, these were allocated to three domains (vitality, comfort and emotional wellbeing [EWB]) with a scoring algorithm derived using item loadings. Subsequently, the owners of 36 healthy and 58 sick cats completed one or two (n = 48) assessments. Median scores (healthy vs sick) for all domains were significantly different ( P <0.001), 78% of cats were correctly classified as healthy or sick and for comorbidities the correlation coefficients were moderate (vitality 0.64; comfort 0.63; EWB 0.50). Test–retest reliability was good (ICC vitality 0.635; comfort 0.716; EWB 0.853).

Conclusions and relevance

This study provides initial evidence for the validity and reliability of a novel HRQoL instrument to aid the assessment and management of chronic diseases of cats.