Five-step process will help you develop vaccine protocols in your practice

The recent publication of the new canine guidelines by the American Animal Hospital Association (AAHA) is creating some debate throughout the veterinary profession and has hit a little closer to home for even more practitioners.

Last year, the Journal of the American Veterinary Medical Association (JAVMA) published research showing feline sarcomas occurred about once in 32,000 immunizations, rather than the 1 in 10,000 previously reported by the initial anecdotal researchers (I say "anecdotal" because of the small "n" used in their research colonies). For the first time in my professional career, our associations have caved in to the public power curve, and have issued guidelines and positions that are not based on solid scientific research.

The new reality is that the AAHA Canine Vaccination Task Force has written abundant guidelines for the vaccinations of our canine patients, and even shared the "estimated titers" reflecting the "estimated minimum duration of immunity (DOI)"; the kicker is in the article's summary section. During the last few years, some university researchers have published skip-year vaccine protocols, but the respective veterinary college deans have refused to adopt them as solid research or "policy". Missouri is not changing its immunization protocols from the United States of Department Agriculture-approved vaccine inserts, since there is no liability protection if they do. There has not yet been anyone or any company to come forward and state they are willing to support the individual practitioner or practice when the skip-year vaccine case goes to court; you are on the limb all by yourself.

The AAHA Canine Vaccine Task Force had 14 members, 12 are diplomates, yet that will not help your case when the court reads the guideline summary statements. The complete AAHA Canine Vaccine Task Force report is available from www.aahanet.org. The AAHA guidelines show the practice just what material is being made public, and it will be the proactive practice that minimizes the client response (not coming in for annual vaccines). The AAHA Task Force also stated, "...informed consent...is an ethical and legal requirement of biological use...Vaccine decisions must be approached like any other medical decision."

Figure 1.

We have seen a few practice alternatives already effectively working with alternating-year vaccines:

• Some practices refuse to deviate from the biological label until someone is willing to officially share the liability; some vaccine manufactures say they will support skip-year vaccines, but nothing has been provided yet in writing.

• A few practices have started to give vaccines away, to remove the cost of the vaccines from the client's excuse/claim process (and they have concurrently ensured the consultation fee is adequate to cover the vaccine cost).

• Some practices are already staggering vaccines so only one vaccine is given at a time, and only one three-year vaccine is given each year.

We have encouraged practices to make an annual examination a requirement for receiving vaccines, then determine if the animal will be shifted to a skip-year protocol.

We also recommend practices see an animal three to six times a year. A majority of these visits are for wellness examinations so a technician can see the patient.

In human health care, many doctor visits are scheduled with the skilled nursing staff. If we adopt this "annual doctor-client-patient relationship" as a requirement, then the practice's programs for multiple visits and wellness care visits are less expensive; we save the client the doctor's consultation if the animal is healthy, and we allow the doctors to see the cases which really need their diagnostic expertise (providing higher net).

Consider the spin-off needs when you are planning a year of care, and then seeing the companion animal three to six times during the subsequent 12 months:

• Better follow-up on master problem list entries

• Pediatric needs

• Immunizations

• Heartworm testing

• Parasite and fecal screens

• Nutritional issues

• Skin surveillance

• Dental hygiene

• More than 40 surveillance programs.

• Genetic predispositions (e.g., www.upei/cidd/intro.htm).

• Senior programs

• Chronic condition surveillance.

We actually prefer the health care delivery system where the annual visit is scheduled four to six months before or after the last vaccine, so the visit can be a true "planned" consultation to discuss travel, lifestyles, age factors, genetic predispositions, and changes in the home environment, and also be a visit where nothing invasive is done. By having this "annual life-cycle consultation", they qualify for preferred client/patient status, which means lower cost nursing appointments are now available to them.

Setting a foundation

With the new AAHA guidelines, and the obvious personal liability to the practitioner, protocols will need to be developed, and this includes for all vaccines. Cornell University College of Veterinary Medicine and the feline practitioners have been talking about feline protection guidelines, and the American Veterinary Medical Association (AVMA) and now AAHA have published their positions on canine vaccine guidelines. Practitioners must get copies of these guidelines and develop a single standard that fits within their comfort zone for liability as well as good medicine. We recommend the following steps when establishing your new practice protocols:

Table 1: Developing Guidelines for Protocol Changes

• 1. The first step is a practice must get copies of the recent guidelines from AAHA, Cornell, American Association of Feline Practitioners, AVMA and its regional veterinary school(s), then discuss the standards of care.

• 2. The second step is integrating the new vaccination philosophies into the practice's standards of care and establishing the documentation expectations for continuity of care. There can only be one policy. The staff is expected to convey the practice expectations to clients; individual doctor differences must be eliminated immediately!

• 3. The third step is developing the practice-specific policy, which means each provider accept a single standard for determining eligibility of a companion animal for entry into a skip-year immunization program. This could be based on outside exposures, age, number of pets in the household, traveling with the pet, community threats/standards or a host of other factors extracted from recent literature.

• 4. The fourth step is developing the practice-specific consent form, which must explain very clearly the danger from vaccination (e.g., 1 in 32,000 cats get a sarcoma), as well as the danger from not vaccinating (e.g., the extended duration of immunity of vaccines have not yet proven by significant "n" titer-challenge testing approved by the USDA). The drug inserts have not been changed, and even the veterinary schools do not yet agree.

• 5. At implementation, revised adult animal protocol narratives need to be rehearsed and role played, which will be different from the traditional puppy and kitten protocol narratives (which also should be role played and rehearsed). The practice leadership must ensure all practitioners within a specific practice have similar narratives to discuss the same standards and the same explanation of the consent form. This allows staff to represent the practice and state the "practice standards" without being chopped down at the knees by the client or a doctor.

As an added twist, for team-based veterinary healthcare delivery, we believe the "annual life-cycle consultation" should spin-off other healthcare needs, most of which will be followed by the nursing staff (no doctor's consultation unless there is a reversion or newly emerging health problem), such as: skin recovery, nutritional surveillance, parasite prevention and control, dental hygiene, over-40 genetic predisposition testing, behavior counseling and sequential laboratory testing for atypical blood chemistries.

As patient advocates, we also expect all deferred or symptomatic care to be assigned to a nursing staff member for follow-up, which will continue at least weekly, or more often as indicated, until the master problem list shows resolution of the presenting complaint.

Why do I mention these last two areas when discussing skip-year vaccines? Because it is the opportunity to "raise the bar" in client education, increase the return rates due to good medicine, and the planning should be integrated (#2 as previously mentioned, p. 11) into the balance of the practice programs. Address skip-year vaccines as well as the need for multiple visits per pet, per year. (One dog year is seven people years in the mind of most of our clients, so quarterly visits is not a bad expectation.)

Remember these key points when developing the new practice vaccination protocols:

• The front door must swing for a practice to survive.

• In the absence of knowledge, all decisions are based on price.

• As client awareness increases, so does their practice visits.

• No reasonable adult would stay away from their physician for seven years.

• Affordable health care includes interest money from Care Credit.

• Affordable healthcare should include using the Veterinary Pet Insurance Superior Reimbursement Tables for price comparisons when clients ask about the practice's fee schedule, so you never compete within a local community. They could even buy the indemnity insurance (like car insurance) if they want to "share the risk" with a reputable insurance company.