Spring 2014 | Vol. 11, No. 2
A WealthEnhancing Resource for Independent Veterinary Practices
Diagnosis: Oral Pain 3 | The Pruritus Workup 8
Osteoarthritis in Senior Cats 15 | Generic Drugs: Profit Potential 21
Announcing a Breakthrough in Canine Screening. Better Science for Better Medicine.
>99%
SUPERIOR HEARTWORM DETECTION
MORE INFORMATIVE
Detects 35% more single-worm infections than in-house kits
Indicates both natural exposure and vaccination status
LYME TEST
EARLIER E. CANIS DETECTION
BETTER VALUE FOR YOUR HOSPITAL
Detects exposure one to two weeks earlier than in-house tests
No more fretting about test kit inventory, expiration dates and faint blue dots!
Brought to you by ANTECH’s revolutionary Bio-CD. The ANTECH® Bio-CD platform is a first for the veterinary industry, employing a combination of laser beams and fluorescence to detect antibodies and peptides on a bioactive silicon disc surface. This automated system, adapted from advanced physics research, gives ANTECH the capability to run highly-multiplexed assays on a single drop of serum.
For more information, visit AntechDiagnostics.com/AccuPlex.
From the Desk of Dennis A. Nelson, dvm FELINE OSTEOARTHRITIS: AN UNDERDIAGNOSED DISEASE
Spring 2014 | Vol. 11 | No. 2
A Wealth-Enhancing Resource for Independent Veterinary Practices Your Veterinarian Pet Care News From ®
$4.25
A WealthEnhanc ing Res for Inde ource penden Veterina ry Practic t es
11, no. 2 spring 2014 | Volume
CH DITITCH
Spring 2014
| Vol. 11,
No. 2
THE
Relief for your pet’s itching and scratching
THERE’S THE RUB is Treating feline osteoarthrit
Diagno
sis: Ora l Pain 3 | The Pruritu
s Worku
p8
Does Your Pet Have a Toothache? Generic Drugs: Lower Cost Options Osteoa
rthritis
in Sen ior
Cats 15 | Gen eric
Drugs:
Profit
Potent
ial 21
The Team is published to complement Pet Quarterly®, an educational resource for your clients. Look for these articles in the current issue of Pet Quarterly: Does Your Pet Have a Toothache?; There’s the Rub; Ditch the Itch; Going Generic.
An estimated 80 percent to 90 percent of senior and geriatric cats suffer from osteoarthritis, but it’s one of the most under-diagnosed feline diseases. Cats are masters at hiding pain, and they rarely show signs of limping or lameness. They often resist Purchasing Services, Inc. announces a new examination—and many are PSI Member Business Symposium to be held not receiving veterinary care. But simple changes at home June 12-15, 2014, in St. Petersburg, Fla. along with treatments such as Stay tuned for more information. laser therapy can help cats live more pain-free lives in their golden years. Get your whole team up to speed on spotting signs of this degenerative disease. On pg. 15, Dr. Stephanie Gandy Murphy provides an overview of diagnoses and treatment suggestions for everyone on your practice team.
SAVE THE DATE...
A lso in this issue: Visit us on the web at
www.psi-inc.net
The Team is an educational resource published by Purchasing Services Inc., St. Petersburg, Fla. Comments are welcome at info@petquarterly.com
• Pets with oral pain will often still eat, play and work. Dr. Sharon Hoffman has advice on treatment and compliance on pg. 3. • Pruritus is a complex problem that requires a methodical workup. Dr. Michael Canfield takes us through the process and offers suggestions for gaining client compliance on pg. 8. • Are you using generic drugs in your practice? If not, you might want to consider the pricing flexibility—and profits—that come with nonbranded drugs. They are just as safe as branded drugs and cover a range of conditions, from osteoarthritis to respiratory and urinary tract infections. Read more on pg. 21. We hope you find this issue both educational and wealthenhancing for your business.
Visit us on the web at www.psi-inc.net © Copyright 2014. All rights reserved. The Team magazine does not make any representations as to opinions or facts as presented. Reproduction of contents in any form is prohibited without prior written permission of the publisher. Postmaster: Send address changes to: The Team, 2951 34th Street South St. Petersburg, FL 33711
Sincerely,
Dennis A. Nelson, DVM Vice President, Operations Purchasing Services Inc.
www.psi-inc.net | the Team | Spring 2014 1
Dental Health
Diagnosis: Oral Pain Find the source of oral pain in dogs and cats, and get your team involved in improving compliance. By Sharon Hoffman, DVM, Diplomate American Veterinary Dental College
Key causes of oral and dental pain in pets range from periodontal disease to fractured teeth, malocclusion, tooth resorption and stomatitis. Most pets with painful teeth and mouths will still eat, play and work. How then, will the veterinary team diagnose oral pain and increase pet owner awareness? A pet owner usually won’t see the source of oral pain in a pet. Unlike a sore leg or a visible wound on the skin, broken teeth are hidden behind the lips and periodontal disease is hidden under the gum. Pets with sore mouths may not want their mouths or faces touched. Others will “act old.” These subtle signs of oral pain may go unnoticed. There may not be any signs at all.
Finding the Source of Pain Diagnosing the key causes of oral pain begins with an extraoral and intraoral exam of the conscious patient. This exam will reveal some causes of pain, especially if you find a fractured tooth or malocclusion, or detect an odor. Always compare teeth on the left and right sides of the mouth. If a pet has pain on only one side of the mouth, there may be calculus build-up on that side. The calculus builds up because the pet is avoiding chewing on the painful side. Watching a dog chew a C.E.T. VeggieDent, Greenie or Tartar Shield chew (www.vohc.org for
list of approved chews) in the exam room may help identify pain on one side of the mouth. The dog may avoid chewing on the painful side. Cats and some dogs will not chew anything in the exam room. Pets in severe pain may not allow an oral exam. This is often the case with stomatitis patients.
Exam Under Anesthesia The next part of the oral exam is performed under general anesthesia. This allows you to look in places that cannot be seen in an awake pet. Each step of the exam is essential for a complete and accurate diagnosis. 1. Examine every tooth above and below the gingiva using a dental probe. Measure periodontal pockets and attachment loss. Use a dental explorer to detect tooth resorption and caries. 2. Take dental X-rays of all teeth. 3. Record all findings on a dental chart. Some practices schedule a diagnostic oral exam at the time of the first anesthesia, with a second visit for treatment. This allows time to review photos and radiographic findings with the client prior to treatment. It also makes it possible to create an estimate for needed procedures. Scheduling adequate time prevents time pressure anxiety on the day of the procedure and ensures that there will be enough time to provide the care the patient needs. >> www.psi-inc.net | the Team | Spring 2014 3
Dental Health
1
Treating Oral Pain After you perform a complete oral exam, take radiographs under anesthesia and reach a diagnosis, treatment planning begins. Treatment will require a procedure. Fractured Teeth. There are two surgical options for fractured teeth in which the pulp is involved: extraction or root canal therapy. (Fig. 1) Watching and waiting for swelling or drainage is not an option, as pain and infection will persist. A fractured tooth cannot heal, and antibiotics will not prevent tooth death or infection. Visit www.avdc. org for a referral to a board-certified specialist if these procedures are not provided in your practice. Tooth Resorption. Pets diagnosed with tooth resorption will require surgery. (Fig. 2) The type of surgery needed is determined after reviewing the dental radiographs (see www.avdc.org for types of tooth resorption). Stomatitis. Pets with stomatitis will need surgery involving multiple
A fractured tooth requires root canal treatment or surgical extraction, plus pain management.
extractions. Those with a painful malocclusion may need extractions or referral to a specialist for options such as orthodontics. Periodontal Disease. Treatment options for periodontal disease depend on the stage of the disease (see www.avdc.org for stages), as determined from radiographs and measurement of attachment loss. Any or all of these procedures may be indicated: n closed root planing n perioceutic application n open root planing n implants no ther advanced periodontal procedures. The periodontal patient will
need professional periodontal treatments two to three times a year to control the disease. Periodontal surgery is time-consuming and requires advanced training. Painful dental and oral diseases require anesthesia, surgery and pain management. When talking to a pet owner about surgery, address any anesthesia fears the pet owner may have. Discuss what your practice does to decrease risk factors, such as: identifying preexisting systemic disease with CBC, chemistries, urinalysis and cardiac workups when indicated; constant
2
Teeth having tooth resorption require surgery. The type of surgery depends upon the type of resorption as diagnosed using dental radiographs.
The Team Approach Receptionists When scheduling a dental patient, focus on the importance of the oral exam, including radiographs as well as a dental cleaning. Clean teeth may still be sources of pain. n Allow enough time in the procedure schedule for diagnostics under anesthesia. More time will be needed if treatment is planned. n
Assistants, Technicians Have dental models and pictures in each exam room that demonstrate dental disease. n
SMILE OF THE WEEK
Create a “Dental Patient Testimony” photo book to include the stories of pets that felt so much better after their dental pain was treated. Feature a “Smile of the Week” case on your Facebook page or website. n
Technicians, Veterinarians Attend continuingeducation dentistry seminars to complement your existing knowledge of current veterinary dentistry. Opportunities abound. Resources include www. avdc.org and the Journal of Veterinary Dentistry (JVD). n
4 Spring 2014 | the Team | www.psi-inc.net
Consider featuring a “Smile of the Week” case on Facebook. n Locate your local Board Certified Veterinary Dentist (www.avdc.org). He/she is a
part of your team in delivering optimal dental and oral care to referred patients.
monitoring and recording of vital signs during anesthesia; body-temperature and blood-pressure support; and preemptive and perioperative pain management customized to the needs of the patient. Patients having high anesthesia risk factors can be referred to a Board Certified Veterinary Dental Specialist. Pets with pre-existing cardiac disease, renal disease, immunosuppressive diseases and diabetes often have painful dental disease that needs to be treated. These patients are candidates for referral.
Improving Client Compliance Take photos of diseased teeth while pets are under anesthesia. Showing these photos to pet owners can help them achieve awareness of their pet’s pain. Do not focus on pictures of dirty teeth followed by pictures of clean teeth—clean teeth may still be sources of pain. (Fig. 3 & 4) Show photos of fractured teeth and those with abrasion, as well as wounds and dental attrition caused by malocclusion. Dental radiographs are the most helpful way to demonstrate periodontal disease. First, show radiographs of normal teeth and bone, then compare to radiographs of pets with bone loss due to periodontal disease. This “show and tell” practice is very enlightening. Pictures are worth a thousand words. Use a chart showing different stages of periodontal disease to demonstrate how the disease progresses. When I show dental >>
Simmons Southeast Current Practice Listings
NEW! Northeast Asheville. Solo dr practice on 2 acres. Easily accommodates 2 drs. SA, minimal boarding and grooming. No emergencies. Grosses $835K. $1.725M for Prx & RE. (#NC14B) NEW! SC-PeeDee/Santee River Valley Regions. Only practice in town! Solo dr, mixed prx w/ less than 5% LA. Motivated seller, very profitable practice! $730K for Prx & 1.88 acres. (#SC43M) NEW! Palm Beach County. 1.5 miles to beach. $157 avg trx chg. Solo dr, SA. Boarding and minimal grooming offered. $1.4M for Prx & RE. (#FL22B) NEW! Eastern NC. Charming solo dr practice. SA, no boarding, grooming or emergencies. $812K gross w/ 4 day work week. Only clinic in town! $1.055M for Prx & RE. (#NC13S) West GA. Urgent Sale! ~3,000sf facility on 9 acres. Solo dr. $605K for Prx & RE. (#GA24B) Polk County. Impeccable 3,000SF facility on busy 4-lane highway. Gross in excess of $2M with continual growth. New owner’s income to exceed $370K! $2.530M for Prx & RE. (#FL72S) NE of Raleigh. Solo dr, SA. $540K gross with minimal dr hours. Limited boarding, no grooming or emergencies. Odor free, spacious facility. $1.125M for Prx & RE. (#NC23R) Northwest SC. Opportunity! Prx on 3 acres plus additional rental bldg. 1.5 drs generating $970K, 95% SA & 5% LA. $1.205M for Prx & RE. (#SC32M) FL Panhandle. Beautiful facility in a highly desirable beach community. No grooming or boarding. $590K gross on a 5 day work week. Affluent clientele. $1.115M for Prx & RE. (#FL30S) Blue Ridge Mountains, GA. Uncomplicated and charismatic town. SA, 1.5 drs, grosses $730K. No boarding or grooming. Practice is open only 4.5 days per week. Prx & RE $805K. (#GA11C) Winter Garden. 2013 revenues up approximately 11%. Solo dr, SA. No boarding, grooming, or ER. Quaint, leased facility centrally located blocks from downtown. $220K for Prx. (#FL35G) 1610 Frederica Road * Saint Simons Island, GA 31522 Toll Free: 800.333.1984 * www.simmonsinc.com Email: southeast@simmonsinc.com Licensed Real Estate Broker in AL, FL, GA, MS, NC, SC, TN
3
4 Clean teeth may still be sources of pain. The clean teeth in photo 3 have advanced periodontal disease, as seen in the X-rays in photo 4 taken on the same day as a dental cleaning. www.psi-inc.net | the Team | Spring 2014 5
Dental Health X-rays (Fig. 5) to pet owners, they ask, “How did it [periodontal disease] get so bad?” Periodontal disease is a stealth disease—it happens where you can’t see it. It can begin when the pet is young, especially in small breed dogs. All small breed dogs over the age of two years should have full mouth dental X-rays to screen for periodontal disease.
5
Compare this X-ray of teeth and healthy Periodontium to photo #4 of teeth having advanced periodontal disease.
Specific questions and comments the team may encounter from the client include: 1. What will happen if we do nothing? This is a common question and may be asked for a couple of reasons: fear of anesthesia, financial concerns or the misperception that the pet is not in pain. Be sure to address any anesthesia concerns. Let the client know what payment plans your practice offers. Explain that periodontal disease will progress and cause more pain and damage. Periodontal disease is the leading cause of tooth loss in pets. In untreated severe cases, jaw fractures may occur. Treating periodontal disease early on is less expensive and also prevents more intense oral pain for the pet. 2. How will my cat eat without teeth? This question comes up in those cases of cats with stomatitis when caudal teeth or full mouth extractions are indicated. Reassure your clients that after healing from surgery, the cat will eat without pain. Always discuss how postoperative pain with be managed to address this concern. 3. “The broken tooth doesn’t seem to bother my dog. He is still eating.” This is a common misperception. A pet owner is not trained to recognize signs of pain in pets. Let clients know that pets with fractured teeth will continue to eat, play and work. Some pets with fractured jaws even still eat. Share stories of pet owners who have noticed dramatic rebounds in energy and playfulness after treatment, and didn’t realize until then how much pain their beloved pet had been in. Stress to clients: We don’t know how much pain the pet is in until we take that pain away. n Dr. Sharon Hoffman is a Board Certified Veterinary Dental Specialist at North Florida Veterinary Dentistry & Oral Surgery in Jacksonville, Fla.
6 Spring 2014 | the Team | www.psi-inc.net
www.psi-inc.net | the Team | Spring 2014 7
Parasites & Dermatology
THE PRURITUS WORKUP How to approach the often-complex issue of itchiness— and improve client compliance. By Michael Canfield, DVM, DACVD (Diplomate, American College of Veterinary Dermatology)
Spring is upon us, and with the change in seasons we can expect to see a rise in the number of
patients presenting with pruritus. This intense feeling of itchiness is the most common symptom in dermatology and is a common presenting complaint in practices across the country. It may stem from a dermatological disorder or may occur without a primary skin disease. Pruritus in dogs and cats may manifest as chewing, licking, scratching, rubbing and excessive grooming. Early in the course of a disease state, these changes usually go unnoticed by most pet owners. However, as observant clinicians, we can detect early changes and point them out to pet owners, starting the educational process. Pruritus is a complex problem that can affect the quality of life for pets and their families. With a methodical diagnostic workup, you can help each client along on a journey to discover the cause of the problem and help each pet find relief.
The Road to Relief Every clinician should have a list of differential diagnoses for pruritus and an understanding of how to rule out the differential diagnoses: allergic, parasitic, inflammatory, neoplastic and
neurogenic. (See sidebar.) Different types of itch include: dermatologic, systemic, neurogenic/neuropathic, psychogenic and mixed, along with other unexplained causes of pruritus. Not every case will be easy. Pruritus is the hallmark of clinical signs for allergic dermatitis, but pruritus is not specific for allergies. An orderly process will help you provide exceptional care and gain compliance. Start with the patient’s signalment, history and physical examination. In particular, note the age of onset. A puppy or kitten presenting with
pruritus will have a different list of differentials than an older dog or cat. Sarcoptic acariasis, demodicosis, dermatophytosis, internal parasites and food sensitivity are much more common in young patients. If an older patient with no prior history of skin disease now has erythema, scale and pruritus, the culprit could be epitheliotropic lymphoma or, less commonly, allergic dermatitis. Base your diagnostic algorithm for pruritus on the information gathered. Although you don’t need to perform every diagnostic test on every patient,
Common Causes of Pruritus Allergic
Parasitic
Inflammatory
Flea allergy dermatitis n Atopy n Atopy-like dermatitis n Food hypersensitivity n Parasitic hypersensitivities n Contact dermatitis n Drug hypersensitivities
Fleas n Ticks n Sarcoptes n Demodex n Lice n Mosquitoes n Culicoides
Bacterial n Fungal n Immune-mediated diseases n Irritant reactions
n
8 Spring 2014 | the Team | www.psi-inc.net
n
n
Neoplastic n
Epitheliotropic lymphoma n Mast cell tumor(s)
Neurogenic n
Psychogenic and sensory neuropathies
>>
Diagnostic Tree for Pruritus Endoparasites
Coproscopic exam/ Fecal Analysis
Ectoparasites
Inflammation
6
4
No
Yes
Skin scrapings Tape preparations Flea combing Cytology Therapeutic Trials +/- Biopsy
Elimination Trial
Ascarids, Hookworms, Tapeworms, Whipworms, Coccidia
Treat
Fleas, Sarcoptes, Ticks, Notoedres, Lice, Cheyletiella, Mosquitoes, etc.
4
No
Yes
Response
6
4
No
Yes
Look for Underlying or Predisposing Cause
Flare upon challenge
Empirically treat. Preventatives where appropriate
SOURCE: ADAPTED FROM MULLER & KIRK’S SMALL ANIMAL DERMATOLOGY, 7TH EDITION, MILLER GRIFFIN CAMPBELL (ELSEVIER 2013).
6
Psychogenic or neurologic disease
Atopic Dermatitis
Food Hypersensivitivy
www.psi-inc.net | the Team | Spring 2014 9
Parasites & Dermatology
Mosquito bite hypersensitivity
Demodex mite from cat
Hookworm ova
Atopy
Flea allergy
Dog louse egg
Whipworm ova
The Team Approach Here’s how the whole team can work together to educate clients about pruritus.
Veterinarians Decide on the educational process that makes the most sense for the practice. Consider covering a single topic in detail at a monthly team meeting, focusing first on the more common disease processes. Consider training your technical teams on how to perform the various diagnostic tests for pruritus.
Technicians/ Veterinary Assistants You are key for interactive client education, but getting prepared to talk about pruritus requires an investment of time. Although much information is available through journals or online, the messages may vary and this is less than ideal for the practice. Practice presenting topics to
10 Spring 2014 | the Team | www.psi-inc.net
the entire team to learn from each other, get your messages consistent and polish your deliveries. Practice answering questions to simulate an examination room setting.
Receptionists Participate in the team training on pruritus. You should be able to reiterate and reinforce the recommendations made by the
hospital team. Document any information you gather related to the pet.
Practice Managers Allot ample time for mandatory team training about pruritus. Reward the team for furthering their knowledge base. Consider modifying performance evaluations to reflect each team member’s level of participation.
every practice should have a list of core diagnostics that are performed on every pruritic patient. All pruritic patients should have: n flea combing n skin scrapings n cytology of the skin and ears.
Diagnostic Tests Here’s an overview of those core tests, as well as other tests that may uncover the cause of pruritus. n Flea combing can be an invaluable diagnostic test to screen for fleas, flea feces, Cheyletiella and lice. n Skin scrapings and hair plucks should be performed to rule out demodicosis, Notoedres and pelodera or to screen for Sarcoptes mites. Always use caution when attempting to eliminate Sarcoptic mange or Demodex gatoi, due to frequent false negative scraping results. Adjust the method you use to collect the samples to fit the differentials. For example, Demodex canis mites are often found in the hair follicles, requiring deeper scrapes, while Demodex gatoi and Sarcoptes scabei are more superficial, generally requiring broad superficial scrapes. n Fine needle aspirates and cytology should be performed to evaluate for lesions such as mast cell tumors and epitheliotropic lymphoma, among other things. n Fecal centrifugation should be performed regularly to screen for intestinal parasites such as hookworms, roundworms, whipworms and coccidia. These have been documented to result in parasitic hypersensitivities, which may result in the development of pruritus. This diagnostic test is seldom thought of for pruritic patients, but it should be a part of the minimum database in most cases. Interestingly, there are times when Demodex gatoi, a cause of pruritus in some cats, may be found in a fecal analysis more readily than with skin scrapings. Fleas, mites and lice may also be seen, especially in allergic animals that have escalated grooming. n An empirical scabies treatment serves as a diagnostic test. Any patient for which atopy will be pursued should be empirically treated for sarcoptic mange.
The reason for this recommendation is that a patient with sarcoptic mange may have a low number of mites, which will often yield a negative skin scraping. Unfortunately for us, sarcoptic mange mites will cross-react with dust mites during allergy testing. Since dust-mite hypersensitivity is common in pets, this simple lapse in diagnostic planning could result in a patient being on immunotherapy the remainder of its life
for a problem it may not have. n Fungal cultures (DTM) should be collected and utilized any time you suspect dermatophytosis—and it should be suspected in any young dog, cat or immunosuppressed patient presenting with fractured or broken hairs. n A Wood’s lamp examination is an inexpensive screening tool for dermatophytosis, but false negatives and false positives are frequent. >>
Approximately 15%
of itchy pets have atopic dermatitis and are candidates ® for ALLERCEPT
What makes ALLERCEPT® Allergy Assessment and Treatment Program the answer? Accurate results with patented IgE-specific technology. NO false positives with Fc receptor. Free case consultations with Heska’s Veterinary Medical and Technical Consultants. 48-hour turnaround on test results.
Special Offer for PSI Customers
Save an additional 8%–10% when you purchase Heska’s convenience pack of 3 regional or 3 regional/food combination panels. Use your tests anytime throughout 2013. Call 1-800-GO HESKA (464-3752), option 1 to redeem your special offer today. ©2013 Heska Corporation. All Rights Reserved. HESKA and ALLERCEPT are registered trademarks and Smarter, Together is a trademark of Heska Corporation in the U.S. and other countries. www.psi-inc.net | the Team | Spring 2014
11 Source code: ADAL0313BG
Parasites & Dermatology Exercise caution with this test. n Cutaneous cytology should be performed on all cutaneous lesions to determine if secondary infections exist and to aid in determining appropriate treatments. n Biopsy of masses or cutaneous lesions should be performed in cases where cytology and other diagnostics are inconclusive or suggestive of immune-mediated disease. n Intradermal or serum allergy testing should be performed when history and physical examination findings are supportive of atopic dermatitis and other causes of pruritus have been ruled out. Atopic dermatitis is a diagnosis of exclusion.
Educate for Compliance Education is the key to compliance in a pruritic patient workup and treatment recommendations. Focus the discussion on the most likely diagnoses based upon the information collected during the examination and history-gathering process. Practice your delivery. Speaking to a client about epitheliotropic lymphoma or mast cell tumors can be much more difficult than a discussion about a histiocytoma or fleas. Clients should hear a unified voice from the practice. With a clear, consistent message from the team, you’ll have the best chance of gaining owner compliance and helping each patient find relief. n Dr. Michael Canfield is a board-certified dermatologist at Animal Dermatology South and Animal Hospital of Regency Park, with Florida offices in New Port Richey, Melbourne and Fort Pierce.
12 Spring 2014 | the Team | www.psi-inc.net
New Drug Option A new pruritus drug is an exciting addition to the veterinary pharmacy. ApoquelŽ (oclacitinib) is a new treatment option for pruritic dogs at least 12 months of age. Its novel mechanism of action is unlike anything we have had in veterinary medicine to date. Apoquel inhibits Janus kinase enzymes, particularly Janus kinase 1 and Janus kinase 3, which inhibits pruritogenic, proinflammatory and proallergic cytokines while sparing Janus kinase 2 (important in hematopoiesis and innate immunity). Apoquel’s onset of action has been shown to exceed that of dexamethasone, prednisolone and Atopica in some studies. It is indicated for the control of acute and chronic pruritus and, unlike glucocorticoids, can be used in conjunction with NSAIDs. Allergy testing can be performed while patients are on Apoquel, whereas glucocorticoids preclude allergy testing.
NON-INSURANCE PREVENTIVE HEALTHCARE PLANS
Provide the best veterinary care, without becoming an Insurance PPO.
LEARN ABOUT OUR PROVEN AND TESTED SYSTEM TODAY!
1-888-458-1423 www.preventplans.com
www.psi-inc.net | the Team | Spring 2014 13
Better medicine together You joined PSI to leverage the collective strength of veterinary practices just like yours. At IDEXX Telemedicine Consultants, we also know how collaboration can lead to better outcomes for you and your patients. To learn more, call 1-800-726-1212.
IDEXX Telemedicine Consultants radiology l cardiology l specialty services idexx.com/telemedicine © 2011 IDEXX Laboratories, Inc. All rights reserved. • 100104-02 • All ®/TM marks are owned by IDEXX Laboratories, Inc. or its affiliates in the United States and/or other countries. The IDEXX Privacy Policy is available at idexx.com.
Half-PageAd(PSI)(Brittney)(r1)_Layout 1 1/30/14 11:25 AM Page 1 100104-02 PSI Print ad FINAL.indd 1
11/1/11 2:26 PM
Start the new year off right for you and your pet owners. We care about the health of your patients, that’s why we’ve aligned everything we do around you, your clients and their pets. Consider joining the more than 30,000 prescribers who have turned to us for their compounding needs for over 30 years.
Special pricing on compounded Aminopentamide Hydrogen Sulfate Tiny tabs®! ■
Aminopentamide Hydrogen Sulfate 0.2mg Tiny Tabs, 100ct: 1: $39.00 2: $29.00 3+: $22.00
Also available: ■ Aminopentamide Hydrogen Sulfate 0.5mg/ml Injection Solution: 5ml: 1-2: $45.00 3-5: $39.00 6+: $36.00 10ml: 1-2: $48.00 3-5: $42.00 6+: $39.00 50ml: 1-2: $56.00 3-5: $50.00 6+: $47.00
PSI Members SAVE 10%
FREE STANDARD SHIPPING**
thru 4/30/14 with promo code
WBPSI114.
*Quantity price breaks available.
Visit Order.WedgewoodPetRx.com to review our complete list of compounded preparations and order online with free standard shipping. Use promo code WBPSI114. **Limit one per prescriber. Offer expires 4/30/14. Not for use in food-chain animals. Medications compounded by Wedgewood Pharmacy are prepared at the direction of a veterinarian. Wedgewood Pharmacy does not make claims for the efficacy of its compounded preparations. Price does not include shipping and handling. Free shipping offer is standard shipping for orders placed online. Offer is for one time use.
Brittany, Customer Care Specialist and Merlin We Care the Way You Care® 855.578.6553
Senior Wellness
NEED TO KNOW: FELINE OA An overview of osteoarthritis, a common but under-diagnosed disease in senior cats. By Stephanie Gandy Murphy, DVM
Advances in our profession are enabling our patients to live longer, making the human-animal
bond stronger than ever before. Veterinary teams are seeing more geriatric patients, and with this shift we see more common diseases treated in human medicine. One of the most common (yet under-diagnosed) diseases of our feline patients is osteoarthritis. Recent studies indicate 80 percent to 90 percent of senior and geriatric cats suffer from this progressive, degenerative disease involving the joints. Over time, the cartilage breaks down and bones start rubbing together, creating friction, pain, reduced joint motion (more commonly in dogs than cats) and sometimes bone spurs. So why has this condition gone largely undiagnosed in the feline species? Some reasons are: n Cats not receiving veterinary care n Cats resisting examination n Cats’ small size and flexibility n Cats rarely show signs of limping/lameness nR adiographic changes in cats being more subtle than those in dogs n Cats are good at hiding signs of pain.
Diagnosing Feline OA When examining a senior cat for OA, start with a general physical examination followed by a more comprehensive orthopedic exam, isolating and >>
Laser Therapy: A Healing Light In a therapy laser, a hand-piece is used to deliver a laser light, which sends energy (photons) into bodily tissues, reducing inflammation. This energy is absorbed within the “power-houses” of the cells, the mitochondria. The mitochondria are responsible for the production of adenosine triphosphate (ATP), which is an enzyme our cells use for energy. Once this light energy is absorbed, the mitochondria increase the production of ATP by a chemical change called “photo-bio-modulation.” This leads to healthier cells and tissues, while the cat experiences a warm, relaxing sensation. Laser therapy usually involves a series of treatments, and while results vary, most clients give positive feedback.
www.psi-inc.net | the Team | Spring 2014 15
Senior Wellness
The Team Approach The whole team can work together to make sure your cat owners are aware of feline osteoarthritis: what it is, how it affects a cat’s behavior, and the most current treatment options.
Receptionists Make it a habit to get as much information as possible from the client when scheduling an appointment, regardless of the reason for the visit. Ask questions such as: How old is your cat? Have you noticed any changes in your cat’s behavior such as reduced grooming, inappropriate urination/defecation, or being reclusive? If owners report any inappropriate urination or defecation, ask if they would take a picture of their
cat’s litter box. Always ask pet owners if they have any questions or concerns about their cat’s visit today. Encourage the owner to call with any issues that may arise.
Veterinary Assistants/ Technicians When handling senior cats, be mindful that many of these patients are experiencing some discomfort from osteoarthritis. Use thick towels on the examination table. If the exam
room is cold, consider warming a towel in the dryer before use; the cat and owner will appreciate it. When restraining a cat, avoid quick, rapid movement of the patient’s body. Cats can experience neck and back pain just as humans can. Be aware that signs of osteoarthritis in cats are typically subtle and are often brushed off as “just old age” or behavioral issues. Learn to ask specific questions (sometimes in multiple ways) and to interpret the owner’s response.
Boarding Managers and Kitty Caretakers Identify cats within the boarding facility that may be suffering from pain associated with osteoarthritis. Document the cat’s behavior during playtime. Do you notice that a boarder seems stiff when first let out of the cage? Make sure older cats have soft bedding that is easy to get in and out of (consider towels or mats). Always feel a boarder’s bedding material. Sometimes older cats will
Ever buy equipment you don’t use? Maximize your return on investment by empowering your staff! Introducing Sound-Eklin’s Education Portal ®
Sign in today for complimentary access and be scanning in minutes.
Learn from the experts, using our on-demand video tutorials. We’ll teach you how to: • Perform the FAST exam • Secrets to scanning “the Big 5.” • Introduction to Echocardiography and much more
education.soundeklin.com YOUR IMAGE IS OUR BUSINESS.
Portable Ultrasound Machine
800.268.5354 16 Spring 2014 | the Team | www.psi-inc.net
SoundEklin_PSI_half_page_ad.indd 1
soundeklin.com
8/20/13 3:38 PM
urinate on bedding instead of the litter box. This could be due to incontinence, pain or fear. Familiarize yourself with the therapy laser and its benefits for cats with chronic pain, so that you can offer this additional service to cat owners.
Practice Managers Make sure your practice has easy-to-follow protocols to assess and address pain in cats. These protocols should include details about factors that could affect drug selection, such as other systemic diseases and the patient’s attitude (i.e., renal insufficiency patient, grumpy
patient). By utilizing the same method of evaluation, all team members will be consistent when assessing a patient’s pain. American Association of Feline Practitioner (AAFP) Guidelines, available online at www.catvets.com/guidelines/ practice-guidelines/painmanagement-guidelines, include great questions that should be included in the protocol. Be sure your veterinarians have all the necessary medications and formulations to treat a variety of pain levels, regardless of the ease of administration. Make sure all team members are trained how to safely use the therapy laser.
Disasters never clock out. Neither do we.
Veterinarians Review and follow the current recommendations for senior care in cats and pain set forth by the AAFP. Use a protocol but customize a treatment for each patient as an individual. Consider all formulations of medications you have dispensed (some come in liquids, pills, chews, injections). Demonstrate physical therapy exercises that owners can try at home. Familiarize yourself with products available to help cats as they age, such as elevated food and water bowls, heated blankets and beds, steps to help cats get onto beds, using puppy pads or litter trays instead of boxes, and utilizing
a space heater. Follow up with your clients! Make sure your clients know you are here to support them. If they are having difficulty with one product or another, offer other solutions and encourage their feedback. >>
In the aftermath of any disaster, time is money. That’s why BELFOR’s industry experts work around the clock to provide complete, turnkey property restoration solutions. From cleanup and construction to the decontamination of valuable assets, BELFOR provides prompt, efficient solutions that businesses and homes across America turn to most. So in the event of a disaster, trust BELFOR to get you back to business.
www.belfor.com 610.594.5566, toll free 888.629.4768
www.psi-inc.net | the Team | Spring 2014 17
Senior Wellness manipulating each joint. You could take radiographs as well, but keep in mind that it is usually difficult to detect indicators of OA in cats. Ask the client questions about how the cat moves and any changes in behavior. Compare your results with those of earlier exams, looking at weight loss, muscle atrophy and pain response. In some cases, you may recommend a
trial of medication to see if the cat responds positively to treatment. When obtaining a history from your client, know the common signs of OA in cats: weight loss, muscle atrophy, behavioral changes (such as irritability or depression), inappropriate elimination, loss of appetite, reduced activity, stiffness (primarily when the cat wakes, often seems to resolve throughout
the day), inability or reluctance to jump down from or up onto areas, reduced height of jumping, poor hair coat due to lack of grooming, constipation, and joint swelling.
Treatment: Challenges and Options Treating feline OA can be difficult due to several factors. For example, owners may have difficulty
Keeping Cats Comfortable Suggest these options to clients to help keep their senior cats comfortable at home: nL itter
pans with lower sides for ease of entering and exiting
nP uppy
pads or blue pads with a small amount of litter on them for cats that cannot get in and out of litter boxes
nE levated
food and water bowls
nS teps
to help cats to get to their favorite places
nS oft
bedding. Foam microfiber bath mats are a great bedding option for older arthritic cats. These mats are slightly thicker than a traditional bathmat, easier for a cat to lie on than some cushioned cat beds, and very easy to wash.
nH eated
cat beds (cold, damp conditions seem to worsen clinical signs)
18 Spring 2014 | the Team | www.psi-inc.net
pilling a cat or with the palatability of recommended diet/treats. Owners may be noncompliant and reluctant to pursue treatment, assuming that they are stressing their cat with repetitive veterinary visits. Physical examinations can be difficult. Some cats freeze; others will not allow manipulation of joints to assess for pain; others may require sedation. You may also have difficulty with owner assessment—since cats are not as active as dogs, its not easy to determine if a treatment plan is working. Other systemic diseases may interfere with your treatment plan. For example, older cats with OA may have some degree of chronic renal insufficiency, and many clinicians are reluctant to use NSAIDs in these patients due to kidney clearance. In addition, many analgesic drugs used in other species are not licensed, not available or not tested for use in cats. Available treatment options include: nW eight loss if a cat is overweight nN on-steroidal anti-inflammatory drugs (NSAIDS) nN utraceuticals (diets, treats, injectables, pills, powders, liquids, etc.), including Omega-3 fatty acids, Glucosamine/Chondroitin, ASU (avocado and soybean unsaponifiables) nN arcotic pain medication nA cupuncture nG abapentin nL aser therapy nP hysical therapy/hydrotherapy (See the current issue of Pet Quarterly for some of the challenges of each.)
8
8
Get your whole team—and cat owners—involved in watching for signs of the disease in senior cats. Encourage team members to video patients in the exam room and watch the videos at your next team meeting. Ask cat owners to do the same at home in an environment that’s less stressful than a clinic visit. This may help you identify symptoms to show to your clients so they will be more likely to participate in treatment options. n Dr. Stephanie Gandy Murphy is a feline veterinarian and owner of Catisfaction Cat Clinic in Madison, Ala. www.psi-inc.net | the Team | Spring 2014 19
Another Putney FDA Approved Generic Drug for Veterinary Use
Cockapoo The perfect combination of Cocker Spaniel and Poodle
Putney Enrofloxacin Flavored Tablets The perfect combination of quality and affordability
FDA Approved for Veterinary Use: Putney Enrofloxacin Flavored Tablets Putney Enrofloxacin is a more affordable Baytril® Taste Tabs®.
• Beef flavored • Our FDA-approved veterinary generic is available in the same strengths, scoring and bottle counts as Baytril® Taste Tabs®: 22.7 mg # tablets double scored
68 mg
68 mg
136 mg
136 mg
100
22.7 mg 500
50
250
50
200
✓
✓
✓
✓
✓
✓
• Full veterinary technical support from Putney
Committed to quality. Delivering affordability.
www.putneyvet.com
Putney, your trusted company to make available high quality, affordable products to enhance patient compliance and help make pet care more affordable Contact your PSI representative or contact us directly at 866-683-0660
®
BAYTRIL® is a registered trademark of Bayer Aktiengesellschaft. TASTE TABS® is a registered trademark of Bayer HealthCare LLC. *Based on list price. PUTNEY and the Putney “P” logo are registered trademarks and service marks of Putney, Inc. ©2013 Putney, Inc. All rights reserved. 0501-1001-13b
General Wellness
PROFITING FROM GENERICS Promoting generic drugs in your practice adds up to profits in more ways than one. By Paula Andruss
Everyone’s looking to save money these days, and pet
owners are no exception. Research shows that one-third of pet owners are postponing visits to their veterinarians because of the costs associated with those services.1 For dog owners and cat owners alike, one of the biggest concerns is the high cost of prescription drugs. Veterinarians can assuage some of those client concerns while boosting their own profits by offering veterinary generic drugs when available to treat a variety
of common conditions. With prices that average 25 percent to 60 percent lower than their brand-name counterparts, generic drugs can help practices pass along much-appreciated savings to their clients. They can also help build client trust, grow other services and protect practice pharmacy revenue. Veterinary generic drugs are approved equivalents of branded drugs, with the same active ingredients of the original formulation, says Dr. Tracy Revoir, manager of veterinary
support at Putney Inc., a Portland, Maine-based veterinary generic pharmaceutical company. In order to obtain approval from the U.S. Food and Drug Administration (FDA), generic animal drugs must have the same potency, or amount of active ingredient, as the branded drug, she notes. They also must be bioequivalent, which means they are absorbed in the blood equally to the brand product, and therefore, have the same safety and effectiveness as the brand drug. Generic drugs are also manufactured using the same >>
FAST FACT Drug revenue typically accounts for 25 percent to 30 percent of practice revenue.
GENERIC
BRANDED
DRUG TYPE
Carprofen Caplets
Rimadyl Caplets
Anti-inflammatory
Enrofloxacin Flavored Tablets
Baytril Taste Tabs
Antibiotic
Simplicef
Antibiotic
Cefpodoxime Proxetil Common generics and their brand-name counterparts.
www.psi-inc.net | the Team | Spring 2014 21
General Wellness quality standards as branded drugs. The most common drugs available in generic form today are those used to treat conditions including osteoarthritis, postsurgery pain, and skin, respiratory and urinary tract infections. They include Carprofen Caplets, the generic form of the analgesic Rimadyl; Enrofloxacin Flavored Tablets, the generic counterpart to Baytril Taste Tabs; and Cefpodoxime Proxetil Tablets, the generic form of Simplicef.
very least they can make the same amount of money per prescription as they would on the branded drug and save their clients a lot of money. Or they can choose to mark up the generic more, which still saves their clients money. It’s completely up to them in terms of how to approach it.”
Direct Profits These drugs can be profitable in a variety of ways, says Revoir. The first, of course, is based on cost. Because you pay less for generics, you have more flexibility in terms of how much you want to mark up that drug. “It’s up to practices how to price these drugs based on their philosophy and the cost sensitivity of their clients,” she says. “At the
Sample Case For example, says Revoir, to treat a 75-pound dog with hip dysplasia, a 60-tablet bottle of 75-milligram generic Carprofen Caplets would cost the practice $21, while the branded drug would cost $48. If
both drugs are marked up by one time the cost of the branded drug ($48), so that the practice would make the same amount on both drugs, the client cost for the generic would be $69, and the client cost for the branded drug would be $96. In both cases, the practice makes $48. Or, the practice could mark up the generic drug three times and charge the client $84, a $63 profit for the practice while still offering $12 savings for the client over the $96 cost of the branded drug. “In that case, the client still saves $12 on the generic, and the hospital makes $15 more profit with each generic prescription,” says Revoir, adding that those profits can add up when treating chronic conditions such as osteoarthritis, where the animal may take the drug for the rest of its life. Most importantly, the pet may be more likely to receive the medication it needs to be pain-free.
Side Profits
for Canine Heartworm, Parvovirus, and Coronavirus Features of Rapid Test Kits
- Highly purified antibodies produced by biotechnology for the detection and capture of the antigen - Highly sensitive and specific - Simple and easy to use - Storage at room temperature - Small sample volume - Long shelf life
NEW!
Canine ParvovirusCoronavirus Antigen Test Kit
Canine Parvovirus Antigen Test Kit
Canine Heartworm Antigen Test Kit
www.facebook.com/modernveterinarytherapeutics http://youtu.be/8WUZI6KHDKo
ONE-STEP Canine Heartworm Antigen Test Kit
For Orders & Product Information: Call 888.590.9839 info@modernveterinarytherapeutics.com www.ModernVeterinaryTherapeutics.com
22 Spring 2014 | the Team | www.psi-inc.net
Straight dollars aside, veterinary generics can drive profits in other ways in the practice as well: n Client Retention: If clients feel that their veterinarian is not overcharging them on their medications, they may be less likely to think they’re being overcharged in other areas as well. “That builds trust with them, which is important to client retention,” Revoir says. n Keeping Prescriptions Inhouse: Another issue is that clients are getting savvier about where to get the best prices for their prescription drugs, from online sources to big box stores such as Walmart. “If veterinarians keep their prescription prices reasonable, clients are more likely to have their prescriptions filled at the practice,” says Revoir, noting that drug revenue typically accounts for 25 percent to 30 percent of most practice revenue. n Boosting Services: Also, if clients are not spending as much on pet medications, it frees up more
money for them to pay for important diagnostics or other treatments for their pets. Not only will that allow the veterinarian to treat more pets and improve patient outcomes, those additional services will increase the overall practice revenue as well. “When veterinarians can have more prescribing options, it’s good for everyone,” says Revoir. “The pet will be treated, pet owner compliance can increase and the practice veterinarian can retain that pharmacy business and improve their bottom line.” n Paula Andruss is Cincinnati-based writer. 1. Trone Brand Energy, Inc. Economy driven changes in pet owner behavior. http://www. trone.com/2010/09/economy-driven-changes-inpet-owner-purchase-behavior 2. Babson Consulting Alliance Program. Pricing and purchasing behavior analysis. May 2011.
The Team Approach Research shows that roughly one-half of pet owners are unaware that some veterinary drugs are available in generic form2. Because your clients are familiar with generics for humans, educating them about the availability and cost of these prescriptions is often all it takes for them to try generic animal drugs for their pets when available. Here’s how each team member can contribute:
Veterinarians Educate yourself about the quality behind generics as well as the financial benefits. Research which generics are available and stock them. Educate clients about the availability of generics and help them understand the advantages.
Technicians Educate clients and build trust with anecdotes and personal stories about the benefits of generics.
Receptionists Make sure educational materials about generics are visible in the office. Be informed and available to answer client questions. Reinforce the messages that have already been delivered when clients are leaving the office.
Practice Managers Keep a close eye on drug inventory costs. Stay informed about what is and isn’t available in generic form to help clients save money while making the practice more profitable.
Suburban Surgical Company, Inc. the DIAMOND of the INDUSTRY THE EXCLUSIVE PROVIDER FOR STAINLESS STEEL EQUIPMENT SOME OF OUR MOST POPULAR ANIMAL CARE PRODUCTS INCLUDE: Regal stainless steel cages Laminated cages Classic stainless steel or Regal case & utility carts Classic stainless steel gurneys or Regal Vet-mate Stainless steel & Masonry pen systems For more than 60 years & three generations, SSCI has designed & manufactured the highest quality stainless steel & laminated equipment available for the animal care market. Our goal is to provide our customers with the highest quality products, backed by the highest quality service.
Stainless steel scales including the Regal 300 Stainless steel bathing tables & tubs Stainless steel utility, instrument & over instrument tables Stainless steel IV stands, mayo stands, sinks & receptacles Stainless steel & laminated lift, operating, prep-procedure and exam tables
MADE IN
SUBURBAN SURGICAL COMPANY, INC MADE IN THE USA
275 12th street, Wheeling, IL 60090
www.SuburbanSurgical.com
800.323.7366
www.psi-inc.net | the Team | Spring 2014 23
Are your pet owners happy? “Payment options are still the number one reason for pet owners to be dissatisfied with veterinary care.”*
PaymentBanc can help, it’s as easy as 1..2..3!
1 2 3
One SyStem PaymentBanc offers a simple, secure, web-based portal for veterinary practices to set up managed monthly payments.
twO wayS tO Benefit > Partner Payment Services for Critical Care > Preventive Healthcare Plans
three elementS tO SucceSS > Instant Credit Recommendations > Automatic Check and Credit Card Drafting > Complete Account Management
Payment Plans for High-Dollar Procedures and Wellness Programs
Call us today to get started!
8 8 8 . 75 8 . 0 5 8 3
PaymentBanc.com
*Based on the 2011 Bayer Veterinary Care Usage Study, Bayer HealthCare LLC, Animal Health Division: By John Volk and Dr. Karen E. Felsted (NCVEI) – A comprehensive investigation into reasons for the decline in companion animal veterinary visits over the past several years.
Quiz TEST YOUR KNOWLEDGE
Quiz questions are based on articles in the current issues of The Team and Pet Quarterly ÂŽ
1 True or false: Antibiotics can and tooth death in a pet’s help prevent infection broken tooth. A. True B. False
2 What are two options
for treating stomatitis? A. Orthodontics B. Perioceutic application C. Multiple extractions D. Closed root planing 3 What are the average sav ings on generic drugs? A. 10 percent to 30 percen t B. 15 percent to 20 percen t C. 25 percent to 60 percen t D. 65 percent to 70 percen t 4 What is the generic name for the branded drug Baytril? A. Carprofen B. Cefpodoxime Proxetil C. Oxacillin D. Enrofloxacin 5 Which two causes of pru ritis are more common in younger pets than in old er patients? A. Sarcoptic acariasis B. Epitheliotropic lymphoma C. Allergic dermatitis D. Internal parasites
6 What do skin scrapings and hair pluckings help to detect? A. Demodicosis C. Lice B. Cheyletiella D. Ringw orm 7 Which statements are tru e about Apoquel, a new pruritus drug? A. It inhibits Janus kinase 2. B. It may be used in conjun ction with NSAIDs. C. It may be used during alle rgy testing. D. It is a steroid. 8 Which statement about fel ine osteoarthritis is not true? A. An estimated 80 percen t to 90 and geriatric cats suffer fro percent of senior m osteoarthritis. B. Radiographic changes in cats are more subtle than those in dogs. C. Cats rarely show signs of limping/lameness. D. Loss of appetite is not a sign of osteoarthritis. 9 True or false: Many analg esic drugs used to treat osteoarthritis are not lice nsed for felines. A. True B. False 10 Which are common health concerns for Great Pyrenees? A. Osteochondrosis B. Lymphoma C. Exocrine pancreatic insuffi ciency D. Gastric Dilatation Volvul us
1-B; 2-A,C; 3-C; 4-D; 5-A,D; www.psi-inc.net | the Team | Spring 2014 25
6-A; 7-B,C; 8-D; 9-A; 10-A,D
It’s the procedure you perform only once in your career.
So it’s important to have the right people by your side. You wouldn’t walk into a complicated surgery without an expert team, so why do it for this once-in-a-lifetime event? Buying or selling a practice is the largest financial transaction of your life. That’s why you should partner with Simmons. As the most experienced brokerage firm in the business, we’ve helped more veterinarians realize their dream than any other firm out there. In fact, we wrote the book on it. We really did write the book on buying and selling your veterinary practice. Scan the QR code or visit our web site to learn more.
w w w. s i m m o n s i n c . c o m
your future
|
our business ©2013 Simmons, Inc.