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Clinical audit is a term being used throughout the human medical world - and the need for it to become a normal part of veterinary practice appears to be  indisputable

Written by Mike Davies BVetMed CertVR CertSAO ACIArb FRCVS

Without objective measurement of clinical performance how can we be sure, as clinicians, that we are doing the best for our patients ? The answer is - we can't ! 

If we can't be sure about our clinical success rate - our clients can't be sure either so, when problems do occur, we are open to criticism of our clinical standards. The only way to protect ourselves against such criticism is to put in place an objective system for clinical auditing.

In addition, if we genuinely wish to strive to provide the best clinical service for our patients we should want to perform clinical audits so that we can be reassured that our standards are at least as good, if not better, than our peers. We should want to identify our clinical weaknesses and work to improve them through continuing professional development.

This means introducing some way of measuring the success of our  :

• Diagnosis
• Treatment 

Of course, we all believe that we are doing a good job, and we have clinical impressions, hunches, gut  feelings, or anecdotal evidence that the presumptive diagnoses we make and the medications that we prescribe on a daily basis are correct and work most of the time. We certainly do know about the cases in which initial treatment does not work because we then need to perform a more detailed work-up.  But, in fact, we can rarely be sure that an unconfirmed diagnosis is correct or that a treatment we give is necessary or beneficial to the animal. Could medications we prescribe regularly actually be totally unnecessary or even detrimental ? 

How do we know  which of the preparations on our pharmacy shelves are more or less effective than others for the treatment of a specific condition in our practice ? Which offer best value to the fee paying client ? The most expensive drug might be most cost-effective if it cures a disease quicker than a cheaper equivalent, or if a patient with a recurrent disease stays in remission for longer.

Can we rely on published scientific evidence to support the efficacy of our treatments  ? The answer is -  both YES and NO ! 

With POM pharmaceutical drugs there is a long-established system of in-depth, independent scrutiny of scientific evidence to support efficacy and safety claims before a license is given, so we can be reassured that the claims are, in the opinion of our appointed experts -  valid. The same level of  reassurance can not currently be provided for the use of nutritional supplements, nutraceuticals or alternative remedies such as herbalism or homeopathy. 

Many commonly used surgical procedures also rarely have well designed studies with valid statistical methods and controls built-in to support their use, and  long term evaluation and follow-up studies with large numbers of patients in multiple sites are usually not available. For example, what is the true occurrence rate of mid-line wound dehiscence following routine ovarohysterectomy in bitches ? How many require repeat closure for a small hernia at the surgical site? What is the relationship to different suture materials, or surgical techniques in common use ? Do some clinicians have a higher failure rate than others ? If so, why ? How can these wound breakdowns be prevented ?

Even if there is a lot of valid published work in the literature - there are  problems with this form of scientific evidence because studies have usually been conducted in a laboratory environment, or within a secondary or tertiary referral centre. These environments bear little or no relationship to the situation that applies in your practice. A written up series of successful heart transplants performed in a centre of excellence on the Moon would not justify the performing of routine heart transplants in your practice where the success rate is likely to be significantly less !

Measurement of clinical performance is specific to you, and to your practice. Clinical expectations for a case will depend upon a myriad of different factors to do with the type of case, and to do with YOU  :

• Your knowledge
• Your training
• Your skills
• Your experience
• Your interests
• Your confidence
• Your attitude

The outcomes that you can realistically achieve will often vary greatly from those in published reports depending upon the spectrum of patients that you see, and the client-base that you have in your practice. Important factors include :

• Whether you work  in a first opinion or referral practice
• The type of animals that your practice sees
• The number of cases of a specific type that you see
• Social factors - eg type of  households that your practice serves
• Geographical location
• Local environmental factors eg urban v rural factors 
• Local economic factors

A simple example is the management of road traffic accidents. Clinicians working in rural areas see far fewer accidents than those working  in urban areas - so they have less experience, and fewer cases on which to practice and refine their skills. Clinicians working in specialist emergency clinics have far more experience and skill in applying critical care techniques than others, and so on.

Why should you perform clinical auditing ?

1) Auditing will help you to identify areas of strength and weakness in the clinical services that you and other veterinarians provide within your practice.

If you identify areas of weakness in individual clinicians :  

• Focus on them for additional training to improve performance. In this way the available finance and time resources for continuing professional development within the practice can be channeled into activities which will  improve the clinical services provided by the practice
• Refer cases internally within the practice to colleagues with a better success rates in those areas
• If the whole practice identifies an area of weakness it should recognise the fact and either internally (by training or recruitment) develop the skills and experience needed to provide an adequate service, or build a relationship with a referral centre to whom cases can be referred.

Areas of strength can be marketed to your clientele.

2) Auditing will help you to identify the most efficacious  and cost effective treatment regimens for your population of patients. It will also help you to identify the least efficacious.

For example, let's consider otitis externa.

If you have 5 different polytherapy preparations for otitis externa on your practice shelf you could review the otitis cases that your practice have treated in the past and, for each product and for each clinician, you could determine :

• Average time +/- SD for clinical signs to reduce
• Average time +/- SD for animals to come off treatment
• Recurrance rate - average number of times otitis recurs in your patients following successful treatment, the average time lapse between each recurrence
• Compare the above criteria for different dosing regimens that your clinicians may use 
• Compare the success of treatment in otitis cases with a confirmed cause with the success of empirical treatment in unconfirmed cases. 
• Determine the number and types of cases for which additional laboratory or other investigations are needed
• Determine the type of cases which (in your practice) are most likely going to progress to chronic otitis externa and for which surgery may be needed later
• Calculate the average cost for different treatment regimens, and different clinicians. 

If you do this exercise you will  find :

• The most effective therapeutic agent for first line treatment of unconfirmed otitis externa in your practice population
• The least effective preparation
• The most cost effective preparation
• The least cost effective preparation
• The clinician applying the best treatment regimen
• The clinician applying the least successful treatment regimen
• The relative value of confirming the diagnosis v treating without confirming the diagnosis
• Identify the patients in your population which are most likely to develop chronic otitis and require surgery later
• You will also identify areas in which you/your practice could improve it's management of otitis externa cases

This exercise will improve patient care and, if you're lucky, you may also be able to reduce the number of preparations that you stock on the shelf and so improve stock movement, stock control, attract higher discount on higher volume products, and improve profitability. 

The whole practice will be reassured by the clinical benchmarks that you have set, and all future performance (eg for a new clinician or a new product) can be compared objectively. Your benchmarks can be compared with those reported in the established literature on the subject. However, your information becomes even more valid and important if it is pooled and compared with results from other practices of a similar type in your geographical area - you can then see how your successes and failures compare with your peers. 

Pooling your clinical audit information with that from practices from further a field helps to give a more global picture of the disease, but can actually dilute the value of the analysis for your particular practice environment.

You can only conduct retrospective reviews and analysis if you record the relevant information accurately but you can use paper or computer-based clinical records and for the medical profession computer software programs already exist that will automatically generate such reports. 

Updated January 2016