October 19, 2017

Checklist Use During Wellness Visits

Does the use of checklists prompt veterinarians to discuss important preventive care topics with clients?
By JoAnna Pendergrass, DVM
Veterinary clinical education could benefit from the use of checklists during companion animal wellness visits, according to the authors of a study recently published in Frontiers in Veterinary Science.1 Study results could support the use of checklists in private practice, noted the researchers.

Wellness visits play an important role in companion animal medicine, allowing veterinarians to thoroughly examine their patients and make recommendations for preventing disease, improving overall health, and enhancing quality of life. These visits also give clients the opportunity to ask specific questions they may have about their pet.

Despite the importance of regular wellness care, the frequency of veterinary visits has declined steadily.2 A survey by the American Animal Hospital Association (AAHA) reported a 17% decrease between 2001 and 2009 in the number of active clients per fulltime veterinarian.3 Also, results of the Bayer Veterinary Care Usage study showed that nearly 15% of dogs and 40% of cats had not had a veterinary visit in the previous 12 months.4

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The Bayer study identified a key reason why veterinary visits decreased: an “inadequate understanding of the need for routine examinations.” This lack of understanding highlights the communication gap between veterinarians and pet owners regarding the value of regular wellness visits.

To address this decrease in veterinary wellness visits, AAHA and the American Veterinary Medical Association collaborated with other organizations to form Partners for Healthy Pets (PHP). PHP has developed several checklists to help veterinarians per- form comprehensive wellness visits that include discussions on a full range of preventive care topics.

Previous studies have reported the benefit of checklists in human medical education, evidenced by improvements in acquisition of clinical skills and clinical examination scores.5,6 To date, however, limited definitive data are available on the use of checklists in veterinary medical education.

Study Design
The current study was conducted during the Community Practice (CP) clerkship at the Virginia-Maryland College of Veterinary Medicine’s Veterinary Teaching Hospital. During this 3-week clerkship, fourth-year veterinary students see dogs and cats for routine wellness visits in which they obtain each patient’s history, perform a physical exam, and formulate an individualized wellness plan.

The researchers selected students from the first 6 blocks of the CP clerkship; 33 students agreed to participate. At the beginning of each block, students received information on wellness visits and PHP wellness checklists. For this study’s purposes, the PHP checklists were modified to reflect health considerations relevant to southwest Virginia. The 19 major wellness topics listed in the checklists were grouped into 4 categories: history, vaccinations, parasite control, and discussion topics (eg, at-home dental care, wellness lab work, scheduling of next visit).

In blocks 1 to 3, 14 students performed their wellness visits without the checklists; in blocks 4 to 6, 19 students used the checklists during wellness visits. All study participants submitted a completed paper record of their visits before presenting the case to the block’s lead clinician.

Results
The researchers analyzed 95 wellness visits. Of these, 72 were canine visits (22 with checklist, 50 without checklist), and 23 were feline visits (11 with checklist, 12 without checklist).

Regardless of checklist usage, students were likely to discuss history, vaccination, and parasite control, yet they were unlikely to mention the discussion topics. Notably, only about half of students with checklists for feline wellness visits remembered to bring up the discussion topics. The unlikelihood of mentioning the discussion topics—even with checklist usage—highlights an important teaching opportunity in clinical veterinary medical education, the researchers noted.

During the canine wellness visits, previous medical history, flea/tick prevention, and heartworm prevention were discussed frequently. Several areas—lifestyle/infectious disease risk, current medications, heartworm testing, fecal exams—were discussed significantly more frequently by students with checklists than those without checklists.

For the feline wellness visits, previous medical history and current diet were discussed frequently. Lifestyle/infectious disease risk, current medications, and heartworm prevention were discussed notably more often by students with checklists than those without checklists.

Limitations and Future Research Ideas
Several factors limited this study. For example, checklist usage was not randomized, possibly introducing selection bias. Observer bias may have also been introduced, given that reviewers of the paper forms were not blinded to whether students used the checklists. Also, student perceptions of checklist usage were not evaluated, leaving it unknown whether students liked the checklists and would voluntarily use them in future wellness visits.

The researchers proposed several ideas for future studies:
  • Determine whether students using checklists perform more systematic and complete wellness visits after graduation.
  • Assess whether checklists improve communication with pet owners about ongoing preventive care.
  • Evaluate clients’ perceptions of checklist usage: Do clients think that checklists convey a lack of knowledge?

Conclusion
Although checklists helped the students perform a more complete wellness exam, they “were not found to be universally effective and did not appear to prompt students to be more likely to discuss ongoing health management,” the study authors noted. Therefore, the researchers recommended incorporating checklists into the teaching and implementation of companion animal wellness in veterinary clinical education.
 
Dr. Pendergrass received her DVM from the Virginia-Maryland College of Veterinary Medicine and completed a postdoctoral fellowship at Emory University’s Yerkes National Primate Research Center. Dr. Pendergrass is the founder and owner of JPen Communications, LLC, a medical communications company.
References:
  1. Nappier MT, Corrigan VK, Bartl-Wilson LE, et al. Evaluating checklist use in companion animal wellness visits in a veterinary teaching hospital: a preliminary study. Front Vet Sci. 2017;4:87.
  2. Volk JO, Felsted KE, Thomas JG, Siren CW. Executive summary of phase 2 of the Bayer Veterinary Care Usage Study. JAVMA. 2011;239(10):1311–1316.
  3. American Animal Hospital Association-American Veterinary Medical Association Preventive Healthcare Guidelines Task Force. Development of new canine and feline preventive healthcare guidelines designed to improve pet health. J Am Anim Hosp Assoc. 2011;47(5):306-311.
  4. Volk JO, Felsted KE, Thomas JG, Siren CW. Executive summary of the Bayer Veterinary Care Usage Study. JAVMA. 2011;238(10):1275-1282.
  5. Hunskaar S, Seim S. The effect of a checklist on medical students’ exposures to practical skills. Med Educ. 1984;18(6):439-442.
  6. Hofer RE, Nikolaus OB, Pawlina W. Using checklists in a gross anatomy laboratory improves learning outcomes and dissection quality. Anat Sci Educ. 2011;4(5):249-255.


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