VCPR- What is sufficient knowledge for presumptive diagnosis? (Proceedings)

The regulatory agencies that license and regulate us include the requirement that we maintain a valid veterinary client patient relationship (VCPR). A taskforce for the Wisconsin Veterinary Medical Association struggled with defining the phrases in the VCPR for our examining board:

     • Medically appropriate and timely visits

     • Personally acquainted with keeping and care of animals

     • Recently seen

     • Sufficient knowledge to initiate a general or preliminary diagnosis

It was difficult because one size doesn't fit all for any of these phrases for either our clients or the individual veterinarians responsible for those clients. As practitioners we will do well to make sure we have defined those for each dairy that we hold the VCPR. The new dairy animal care certification program asks the producers if they have a valid VCPR as the very first question. We will have the opportunity to define VCPR for our clients as we work through the FARM animal care certification program and establish the appropriate values for each client.

     • Recently seen, medically appropriate, and timely visits" is specific by dairy. How we deliver it in a sound business plan for both ourselves and the producer is yet to be discussed but is found as the plan for regular supervision of cows currently under treatment which will be developed as part of an expansion of our fertility programs.

     • "Personally acquainted with care and keeping is the application of production medicine and health care by management group. We need to systematically identify the predisposing risk factor for each management group and monitor the impacts on animal health using their health records.

     • Defining sufficient knowledge for a presumptive diagnosis allows us to concentrate on the medical aspects our health care offering. The knowledge we can glean from our records is:

           o Knowing the pattern of conditions (epidemiology)

           o Using shifts in patterns to trigger diagnostics or shifts in care package risk factors

           o Knowing the outcomes of conditions treated

The cow side recordings established the basis for routinely determining both the epidemiology of conditions and treatment outcomes. Establishing the pattern of clinical cases is an extension of the process used to routinely monitor KPIs except now the plan is to be thorough and not to stop with a few key monitors. For business reasons this needs to be done efficiently and regularly if we are to deliver real time sensitive information specific to the dairy.

For a condition such as mastitis we start with a measure of the incidence rate and then dissect that amorphous mass into information so we understands what is happening when to whom

     • By stage of lactation at the first case

     • By cause of the infection

     • By severity of the case

     • By sub clinical mastitis history

     • By clinical mastitis history

It is nothing more complex than integrating the information of interest for the list of cows that have had mastitis in a period of time as a "summary command". Table 1 demonstrates such a listing which could have been for a month, quarter, or year. Efficiently, the information can be tabulated in the vertical columns while the individual identity of cows can be maintained horizontally. Table 2 demonstrates the mastitis pattern for a real dairy for a year by tabulating the vertical columns.

Table 1 list of 10 mastitis cow with pattern information included. Only records required was a recording of the mastitis case at the time of treatment and including the recording of the culture and SCC

One question would be does it make any difference if the herd represented in table 2 is 100 cows, 1000 cows, or 10,000 cows? The answer has to do with confidence in the numbers. If the herd had only been 100 cows it would probably have been more meaningful to have presented the data as actual number of cows not percentages, but the data would not have changed. The intent to understand epidemiology is not herd size dependent.

Table 2 Herd pattern for the year from a summary command like table 1of mastitis cases for a herd for a year with 15 cases per 100 cows/ year

The only pattern that is unexpected is the proportion of severe cases which can now be investigated. We also have not lost the ability to identify individual animals of interest. Since we know the SOPs and management policy for sensitivity of detecting cases and the herd compliance for following treatment protocols, this represents real value to the dairy to direct activities to either personnel, sub sets of the cows, or diagnostics.

It was done with only the recording of severity and the sub clinical infection information at the time of the case. The herd pattern was tabulated from the list of individual cows therefore the individual identity was still present of any problem cows. This information was demonstrated on a year's worth of cases, since we live in a four season climate it would made sense to have this kind of knowledge quarterly, because the seasons are different.

We have mentioned frequently the value of determining the treatment outcomes. Our initial work for developing the written protocol included finding out what was considered a successful treatment outcome. This is probably the most significant information gathered from the current herd program. We need to have identified perceptions of success and proportions of successful treatments that simply medically unachievable.

The development of the mild condition treatment plan can probably not be written until this happens. Certainly utilizing the AMDUCA algorithm couldn't be followed without some realistic definition of success, which then leads us to defining cows that have a realistic probability of success for either applying label or ELDU protocols in their treatment.

Now we can define some measure that could be considered a successful mastitis outcome:

     • Defining a relapse cow and establishing a satisfactory proportion we want to achieve

     • Defining a successful level of SCC after mastitis relative to SCC pre mastitis

     • Define a threshold period of time a cow needs to remain in the herd to be considered a treatment success

Some of these require exit remark to make the storage of information efficient (days to clinical cure and Days out of tank) and some require monitoring the cow for a period of time after the case. Incorporating the farm personnel for the exit remark is very doable, but is likely to be met with resistance until we find real value for the dairy because it represents a task not currently being done. The most valuable information for the dairy is starting to record days out of the tank. This is the most expensive consideration in the cost of mastitis and from a practical stand point dairies, that start to record it also start to manage it. When we talked about achieving the letter of the law for treatment recording, we knew we needed the number of doses used which can be in the protocol if a herd is limited to top down protocols. Since number of doses tends to be variable it is natural to include it with the recording of days out of tank as part of an exit remark makes the recording easy and efficient.

Table 3 demonstrates a similar process but integrates different information and a delayed time period to assess the outcomes of our treatments

The length of the time period to have sufficient cases for meaning data is dependent on herd. If it is a small herd we need more time to have confidence in our interpretation. A repeat of a caution stated when we were making drug usage decisions, "we said we wanted to present a superior drug protocol and prove it. At the farm level we are not "proving" anything. We are utilizing the records to see if we are satisfied. We are not comparing treatment protocols, which would require a carefully structured field study. We are satisfying ourselves that the protocol satisfies our goal for the welfare of the cow and the food safety for the consumer and is clinically effective at a rate that meets our expectations." We are not doing epidemiology, we are monitoring the pattern and outcomes against what we expect, nothing more.

An important consideration when we are measuring outcomes if we wish to have a realistic opinion is to separate the subsets that do not have the same outcome expectation. For instance chronic subclinical infections are not going to cure as readily and cows that are chronic clinically are also not going to cure well. These are obviously the categories of cows that represent animals with decreased chance of successful cure that can be taught to dairy personnel.

If a SCC cure is defined as the outcome of 1 SCC <200,000 for either of the first two tests post mastitis. What would be an acceptable rate for?

     • A primary case of the cows that were <200,000 pre mastitis

     • A primary case of cows that were >200,000 pre mastitis

     • A second or more infection of cows that were <200,000 pre mastitis

     • A second or more infection of cows that were >200,000 pre mastitis

     • Consider what an acceptable rate is for remaining in the herd for 60 days for a few scenarios?

     • Older animals that are long days in milk

     • Younger animals early days in milk

     • Severe cases versus mild cases

The lists can go on and on and there may not be industry standards for these, but at the herd level these can and should be defined.

This same plan of determining pattern of conditions treated in other management groups can be done in an identical manner for other conditions such as fresh cow conditions, lameness, pneumonia, digestive problems, and replacement animal conditions. All we need to do is determine what pattern measurements would be significant to us and defining what outcomes are satisfactory.

This goes beyond sufficient knowledge to meet the VCPR, this is sufficient knowledge to do supervision of all cases on a regular basis and to recognize when diagnostics and/or modification of the treatment protocol is needed which is the natural application of this level of knowledge.

Conclusion

     • Sufficient knowledge is calculating the pattern of conditions (epidemiology) and endemic pathogens.

     • Defining realistic outcomes to treatment and identifying animals with little likelihood of achieving successful treatment is critical for establishing medically appropriate treatment plans for mild cases.

     • Separate the cows into subsets that allow application of different expectations of successful outcome for different medical histories.