Evidence-based practice

Evidence-based practice in equine clinic: Much more than evidence-based medicine

In the first of this two-part article series, we discussed Evidence-Based Practice in human general practice medicine and how the need to continuously adapt to the needs of the changing population has led to the introduction of the concept of Right Care guidelines.

In this second article, we discuss the proposed four pillars of Equine Right Care, possible definitions and considerations for Equine Right Care and potential sources of high quality evidence to underpin Equine Right Care.

1.- Four Pillars of Equine Right Care

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Just as Greek temples require basic pillars to maintain their structure, Equine Right Care is based on four fundamental pillars:

1. Theoretical-practical knowledge: This includes knowledge acquired during university training, conferences, presentations, etc.

2. Scientific data interpretation skills that permit the clinician to appropriately assess the quality of evidence within any given scientific article.

3. Communication skills; effective team-work and communication with referring vets.

4. Knowledge and application of high quality evidence-based medicine.

2.- Possible Definitions and Considerations of Equine Right Care

According to an editorial piece published in The Lancet, in 2017, Right Care is “in its simplest definition, care that weighs up benefits and harms, is patient-centred (taking individual circumstances, values, and wishes into account), and is informed by evidence, including cost- effectiveness.”

The Right Care system in human medicine was formulated in part because it was considered that the patient’s wellbeing was being overlooked, in deference to rigid medical protocols. 

The concept of Equine Right Care is loosely defined as clinical care that provides more benefits than unwanted effects, using the best available evidence to support the most appropriate clinical decisions, while taking into consideration the individual circumstances of each animal and owner values. 

The concept of Right Care in veterinary medicine includes owner communication and attachment of the owner to the animal, therefore also incorporates important communication skills and information about potential legal issues, and mental wellbeing of the veterinarian. Although similar professional and clinical guidelines do exist in certain countries (e.g., BEVA Guidelines and Primary Care Clinical Guidelines in the UK), such sustained input is not internationally universal and Equine Right Care could be a step towards providing such a framework in countries where it may be welcomed by national committees.

However, the great advantage that we have in equine medicine compared to other branches of veterinary medicine or even human medicine is the few decisions that are made in our daily work, which would facilitate the realization of sources of Right Care.

3.-Potential Sources of Evidence for Equine Right Care

Evidence-based veterinary medicine is fundamental for the provision of high quality clinical standards of care and scientific development. However, relevant literature is not always easily accessible to all equine clinicians, due to lack of relevant online journal subscriptions, time to research, or other factors. 

Appropriate sources of high quality evidence for Equine Right Care would be clinically relevant, peer-reviewed non-commercially biased articles and reviews that convey clear and concise information to support decision-making in daily clinical practice. 

The Cochrane database is an online reference platform managed by a group of clinical specialists in human medicine responsible for evaluating scientific evidence and reaching a consensus as to which articles are included within the reference portal. Recognised human clinical specialists also produce clear and concise review articles on a multitude of clinical topics for busy clinicians to use as clinical reference material. 

Equine Right Care would undoubtably benefit from a Cochrane database-like reference portal, however there are important differences between human and equine evidence based medicine to consider. Firstly, high quality evidence, such as meta-analyses, randomised clinical trials and systematic reviews is much more commonplace in human medicine than in equine medicine, meaning that the human Cochrane database is compiled from a much larger pool of scientifically robust material compared to any potential equine counterpart. Secondly, the creation and maintenance of such an online reference platform is an arduous editorial task, reliant on regular commitment from leading specialists to share their expertise and time.

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Consensus statements commissioned by the American and European Colleges of Equine Internal Medicine and produced by leading equine specialists provide important reference material, however they cover a limited number of important clinical problems and it is accepted that the quality of evidence for certain sub-topics or treatments considered may be low.

Does a further easy access reference portal for high quality evidence need to be considered for the clinical, communication and research skills and wellbeing awareness elements of the Equine Right Care ethos and which form could it take? Food for thought.