Materials and Methods

Study participants—The study protocol was reviewed by the University of Guelph Research Ethics Board and the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health. Veterinarians working in companion animal practices in 14 counties in eastern Ontario were eligible for inclusion in the study. A list of veterinarians designated as spending at least 50% of their time in companion animal practice in these counties was compiled from a database maintained by the College of Veterinarians of Ontario. The order of veterinarians in the list was randomized with a random number generator, and veterinarians were then contacted in sequence until 20 veterinarians had agreed to participate in the study. Because the unit of selection was individual veterinarians, it was possible that multiple veterinarians from a single practice would be selected to participate in the study.

Veterinarians selected to participate in the study were initially contacted by means of a mailed letter of introduction, with a follow-up telephone call 2 to 3 weeks later to inform them of the details of the study and obtain their verbal consent. For veterinarians who agreed to participate in the study, 2 initial study visits were scheduled to begin data collection. As part of the consent process, veterinarians were informed that the purpose of the study was to describe veterinarian-client-patient interactions in companion animal practice and to examine the impact of these interactions on the outcomes of veterinary care. Written consent was obtained from all participating veterinarians at the onset of the first study visit.

With the exception of clients who had scheduled an appointment for euthanasia of an animal, all clients with appointments with the participating veterinarian during study visits were approached in the reception area prior to their scheduled appointments by one of the authors (JBC), who explained the study to potential participants, solicited their participation, and obtained written consent to allow videotaping of the appointment. Participating clients were also required to complete a questionnaire soliciting demographic information about them and their animals, complete an appointment-specific satisfaction questionnaire following the appointment, provide permission for a member of the research team to follow-up with them by telephone within 3 months after the appointment, and provide permission for a member of the research team to access their pet's medical record within 1 year after initial data collection to review events that had occurred since the videotaped appointment.

Data collection—A minimum of 14 veterinarian-client-patient interactions were videotaped for each of the 20 veterinarians participating in the study. At the beginning of each study visit, the principal author and participating veterinarian designated a single examination room in the practice where videotaping would take place, and a video camera was mounted to the ceiling in a corner of that room. To reduce the potential for lost data and prevent biases that could have been introduced by having a researcher present in the examination room, the camera was turned on prior to the first appointment during a study visit, and it recorded continuously for the duration of the study visit. At the end of each study visit, a brief exit questionnaire was administered to the veterinarian to assess the perceived impact of videotaping on the veterinarian's performance that day.

Videotape analysis—All videotaped appointments were classified as wellness or problem appointments on the basis of the reason given by the client for making the appointment. A wellness appointment was defined as an appointment with a presumably healthy pet. A problem appointment was defined as an appointment with a pet experiencing a health-related problem. For each of the 20 veterinarians included in the study, videotapes of 5 wellness and 5 problem appointments were randomly selected for review. If only 4 appointments of a particular type had been videotaped, then 6 appointments of the other type were randomly selected for review.

Videotapes of all 200 appointments were submitted to the laboratory of Dr. Debra Roter at the Johns Hopkins Bloomberg School of Public Health in Baltimore for analysis with the RIAS. During this analysis, appointments were reclassified as wellness or problem appointments on the basis of content of the appointment, and this reclassification was used for all subsequent analyses.

Each videotape was analyzed by a trained coder who assessed verbal and nonverbal communication during the appointment, as described.⁷ The veterinarian-client-patient dialog was divided into individual utterances, with an utterance defined as the smallest speech segment to which a classification could be assigned.¹⁰ Each utterance was then assigned to 1 of 48 exhaustive and mutually exclusive communication variables reflecting the structure and content of the communication taking place between the veterinarian, client, and patient. Interactions were analyzed in 3 directions (ie, veterinarian to client, client to veterinarian, and veterinarian to patient). During appointments involving ≥ 1 client, all client talk was combined.

Identification of cost discussions—To capture information on veterinarian-client communication specific to the cost of veterinary care, 6 proficiency codes were added to the RIAS framework for the present study. Two of these proficiency codes were used to identify talk related to cost during the appointment while also distinguishing whether the veterinarian or client was the first to initiate this type of talk. These proficiency codes were applied when any reference to the cost of veterinary care was made by the veterinarian or client, ensuring that all interactions related to the cost of veterinary care were identified, including vague references to cost (eg, statements by the client such as “We got your notice and can't afford it” and statements by the veterinarian such as “Today I might just have you pay for the booster examination fee”). Whenever 1 of these 2 proficiency codes was assigned to identify talk related to the cost of veterinary care, 1 of the 4 other proficiency codes was also assigned to indicate whether the talk related to cost in general (eg, “You will save yourself about $20 by combining these procedures”), to cost associated with the veterinarian's time or with services provided by the veterinarian (eg, “An ultrasound workup costs about $400” or “I just wanted to let you know that the office visit is $59”), to cost associated with medical information that would be obtained (eg, “The cost of a geriatric screen, which checks 16 tests of organ function—liver, kidney, etc—is about $200”), or to cost associated with future health or function of the pet (eg, “It would be $86 for a general health profile; if it indicates kidney disease, we can change her food. That would help her kidneys and help prolong her life”). Because it was possible for an interaction to contain > 1 occurrence of cost talk, > 1 of the 4 additional proficiency codes could be assigned to any particular interaction, depending on the nature of the talk.

After the 200 interactions were coded, it was apparent that another level of analysis was necessary to capture discussions during which the veterinarian and client addressed the actual price of veterinary care. All interactions initially identified by a coder as containing talk related to the cost of veterinary care were reviewed by the principal author, and the interaction was coded as containing a legitimate discussion of cost when specific references to price occurred.

Cost discussions in relation to specific types of veterinary care—Prior to data collection, the authors identified 8 specific areas of veterinary care (ie, diagnostic testing, dentistry, surgery, medication, heartworm medication, diet, follow-up appointments, and vaccination) that required decision making by the client. After each interaction was RIAS coded, the coder completed an interaction summary indicating whether any decision-making processes related to these 8 areas had occurred during the interaction. A decision-making process was considered to have occurred when an action was taken (eg, the animal was vaccinated) or discussed (eg, medication was prescribed or a change in diet was recommended). When a decision-making process was identified, the coder also indicated whether this included talk related to the cost of the care provided, and all interactions involving talk related to cost were subsequently reviewed to determine whether they contained legitimate cost discussions (ie, specific mention of price).

Blocking with specific markers to indicate the beginning and end of talk related to a certain topic was used to examine the verbal content of each interaction. Six blocking functions were developed and added to the RIAS framework to further explore discussions of cost. Cost discussions involving diagnostic testing, dentistry, surgery, medication, and diet were blocked by coders to capture the quantity of talk devoted to the cost of these topics. The sixth general block function was used to capture the quantity of all other cost talk not related to these 5 areas.

Use of written estimates—As part of the interaction summary completed by the coder, any reference to a written estimate was also recorded. Following coding, all interactions including reference to a written estimate were reviewed by the principal author to identify those in which a written estimate was actually presented to the client by the veterinarian.

Statistical analysis—Descriptive statistics were calculated. Demographic variables were compared between respondent and nonrespondent veterinarians. Contingency table analyses were used for all discrete variables (gender; associate vs practice owner or partner; full-time vs part-time employment; urban, suburban, or rural practice location; and number of veterinarians employed by the practice) with P values calculated on the basis of the Fisher exact test. The Kolmogorov-Smirnov test was used to determine whether continuous variables were normally distributed. The independent t test was used to compare years of clinical experience between groups, and because data were not normally distributed, the Mann-Whitney U test was used to compare base cost of a regular office visit between groups.

Duration of each of the 200 appointments was measured, and the Kolmogorov-Smirnov test was used to determine whether data were normally distributed. Because data were not normally distributed, the Mann-Whitney U test was used to compare appointment duration between appointments that contained a cost discussion and those that did not, with stratification for appointment type.

Practice-, veterinarian-, client-, and appointment-related predictor variables were tested as potential determinants of whether an appointment would contain a cost discussion. To address the complex multilevel structure of the data set, generalized linear mixed modeling was used. Univariate analyses were performed initially to screen potential factors for an association with whether the appointment contained a discussion of cost. All predictor variables for which the P value in univariate analyses was < 0.20 were incorporated into a series of 2-term subset models, including the interaction. Backward elimination techniques were used for model building. Random-effect terms were retained if the estimate was greater than or equal to a quarter of the SE.

All analyses were performed with standard software.^a,b Values of P ≤ 0.05 were considered significant.

Results

Study population—Thirty-three veterinarians were contacted before 20 agreed to participate in the study. The 20 veterinarians included in the study worked at 19 different veterinary practices. Demographic information was obtained from all 13 veterinarians who declined to participate. The primary reason given for not participating was discomfort with having client interactions videotaped. In 3 instances, associate veterinarians who initially agreed to participate subsequently declined because they were unable to secure permission from their employer. In all 3 instances, the employer expressed concern about the potential disruption the study might have on the practice. Participants and nonparticipants did not differ significantly with regard to any of the demographic variables examined.

Overall, 96% of clients (350/366) approached during study visits agreed to participate in the study. Reasons given for not participating included not owning the animal, embarrassment discussing their pet's medical condition on videotape, general discomfort with being videotaped, inability to read the study materials, or no particular reason.

Two study visits were initially scheduled with each of the 20 participating veterinarians; however, to achieve a minimum of 14 videotaped interactions for each veterinarian, a third study visit was required for 3 veterinarians. Number of interactions with each veterinarian that were videotaped ranged from 14 to 28.

For 17 of the 20 veterinarians, 5 wellness and 5 problem appointments (classified on the basis of the client's stated reason for making the appointment) were randomly selected for analysis, and for the remaining 3 veterinarians, 6 wellness and 4 problem appointments were selected for analysis. However, taking into consideration the content of the interaction as observed by the RIAS coders, 95 (47.5%) of the interactions were classified as wellness appointments, and 105 (52.5%) were classified as problem appointments.

Demographic characteristics of participating veterinarians and clients—Of the 20 participating veterinarians, 13 (65%) were female and 7 (35%) were male. Median number of years in practice was 12.5 (range, 2 to 31 years), and 18 (90%) of the veterinarians practiced in clinics where ≥ 2 veterinarians were employed. Of the 19 clinics represented by participating veterinarians, 9 were located in urban areas, 5 were located in suburban areas, and 5 were located in rural areas. At the time of the study, the median base cost of a regular office visit for participating practices was $54.50 (range, $45 to $60; all values in Canadian dollars).

For the 200 interactions that were analyzed, 147 (73.5%) of the clients were female and 53 (26.5%) were male. Mean age of the clients was 45 years (range, 18 to 78 years), and clients represented a variety of socioeconomic backgrounds, with 114 (57%) having completed a college or university degree. Overall, 126 of the 200 (63%) appointments involved only dogs, 68 (34%) involved only cats, and 6 (3%) involved other types of pet, including small reptiles, iguanas, guinea pigs, and chipmunks. None of the 200 appointments involved > 1 species of pet. Pets were of various ages and both sexes.

Impact of videotaping on participating veterinarians—On the exit questionnaire administered at the end of each study visit, 17 of the 20 (85%) veterinarians indicated the videotaping did not interfere with their clinical performance and reported they were able to be themselves in front of the videocamera throughout the study. Two (10%) veterinarians indicated that videotaping interfered during the first study visit but not during the second study visit, although both indicated they were not themselves in front of the videocamera during both study visits. One veterinarian reported that the study interfered with clinical performance.

Data quality—Quality of the audio portion of the videotapes was rated by coders as good (153/200 [76.5%]), fair (41/200 [20.5%]), or poor (6/200 [3%]). None of the videotaped appointments had abrupt beginnings, whereas 6 (3%) had abrupt endings. Because the videocamera ran continuously during each study visit, abrupt endings occurred when the veterinarian left the examination room to perform a procedure on the animal and did not return to conclude the appointment or continued the discussion while walking with the client into the waiting room at the end of the appointment. A pause in video recording was identified during 2 appointments, and in both instances, the pause represented periods of extended absence (> 15 minutes) of both the veterinarian and client from the examination room while a procedure was being performed on the patient.

Although 350 clients consented to participate in the study, 3 appointments were not videotaped as a result of inadequate battery power for the videocamera, videotaping of 4 appointments was terminated in accordance with ethics guidelines in the study protocol, and 4 appointments were not videotaped because the participating veterinarian admitted the client into an examination room where the videocamera was not set up.

Description of the veterinarian-client-patient interaction—Mean duration of the 200 appointments that were analyzed was 17 minutes (range, 2 to 51 minutes), and mean number of utterances during each appointment was 386 (range, 32 to 1,059). On average, 60% of the total conversation was contributed by the veterinarian (range, 35% to 77%), with 54% of the total conversation directed to the client and 6% directed to the pet. On average, the client contributed 40% of the total conversation, with all of the client conversation directed to the veterinarian. Overall, 36 of the 200 (18%) appointments that were analyzed were first-time interactions between the client and veterinarian.

Prevalence of cost discussions—Eighty-one of the 200 (40.5%) appointments that were analyzed contained talk related to the cost of veterinary care. However, only 58 (29%) included a discussion of the actual price (ie, contained a legitimate cost discussion). For 19 of these 58 (33%) appointments, the client initiated the discussion concerning cost, and for 39 (67%), the veterinarian initiated the discussion concerning cost. Five of the 20 (25%) participating veterinarians did not initiate any cost discussions, and 3 of these 5 veterinarians did not have any cost discussions during the 10 appointments that were analyzed. During the 58 appointments with legitimate cost discussions, talk related to cost constituted on average 4.3% (range, < 0.01% to 20%) of the overall dialog taking place during the veterinarian-client-patient interaction.

Nature of cost discussions—Of the 58 appointments with legitimate discussions of cost, 38 (66%) were identified as having a discussion of cost associated with the veterinarian's time or with services provided by the veterinarian, 25 (43%) were identified as having a discussion of cost related to medical information that would be obtained, 10 (17%) were identified as having a discussion of cost related to future health or function of the pet, and 5 (9%) were identified as having a general discussion of cost.

Frequency of cost discussions in relation to specific areas of veterinary care—Cost discussions were most common during appointments in which a decision process related to diagnostic testing was identified (Table 1). By contrast, cost discussions were relatively uncommon during appointments involving decision processes related to heartworm medication, diet, follow-up appointments, and vaccination. The greatest amount of talk regarding cost (ie, highest mean number of utterances regarding cost per appointment) occurred during decision processes related to diagnostic testing, and the least amount of talk regarding cost occurred during decision processes related to diet, with no more than a single utterance regarding cost occurring during any decision process related to diet.

Use of written estimates during veterinarian-client-patient interactions—Overall, reference to a written estimate was made during 28 of the 200 (14%) appointments that were examined. However, a written estimate was actually presented to the client by the veterinarian during only 16 of the 200 (8%) appointments. Reference to a written estimate was made during only 20 of the 58 (34%) appointments that contained a legitimate cost discussion, and a written estimate was presented to the client during only 16 of the 58 (28%) appointments that contained a legitimate cost discussion.

Appointment duration with and without a cost discussion—Duration of appointments that contained a legitimate cost discussion (median, 19.65 minutes) was significantly (P < 0.001) longer than duration of appointments without a legitimate cost discussion (median, 13.64 minutes). Even after stratification for appointment type, wellness (P = 0.034) and problem (P < 0.001) appointments that included a legitimate cost discussion were significantly longer than appointments of a similar type without a cost discussion.

Duration of the 16 appointments that included a legitimate cost discussion and written estimate (median, 20.37 minutes) was not significantly different from duration of the 42 appointments that included a legitimate cost discussion but not a written estimate (median, 18.83 minutes).

Factors associated with occurrence of a cost discussion—In general, few practice-, veterinarian-, client-, or appointment-related characteristics were found to be significantly associated with the occurrence of a cost discussion. One model indicated that after adjusting for random effects and the veterinarian's scheduled time for appointments (ie, 15, 20, or 30 minutes), veterinarians who were strictly small animal practitioners were significantly (P = 0.035) more likely to discuss costs with their clients than were mixed animal practitioners. Results of this model indicated that strictly small animal practitioners were 7.0 times as likely (95% confidence interval, 1.1 to 43.5) as mixed animal practitioners to have cost discussions. Analysis of scheduled appointment times revealed that veterinarians who scheduled appointments every 30 minutes were significantly (P = 0.035) more likely to have cost discussions than were veterinarians who scheduled appointments every 15 minutes (odds ratio, 6.9; 95% confidence interval, 1.3 to 37.0).

A separate model that included terms for number of years in practice, practitioner type, and the interaction between practitioner type and number of years in practice indicated that the odds of a cost discussion decreased as the number of years in practice increased for strictly small animal practitioners, whereas the odds of a cost discussion increased as the number of years in practice increased for mixed animal practitioners. However, the model was limited because only 3 mixed animal practitioners were included in the sample. When data for the 3 mixed animal practitioners were removed from the analysis, there was a significant (P = 0.046) negative association between number of years in practice and likelihood of a cost discussion for strictly small animal practitioners (coefficient, 0.938; 95% confidence interval, 0.88 to 0.99).

Discussion

Results of the present study suggested that discussions related to cost were relatively uncommon during clinical appointments in companion animal practice and that written estimates were infrequently used to aid these discussions. When discussions of cost did occur, veterinarians appeared to focus on explaining costs to clients in terms of the veterinarian's time or services provided by the veterinarian, rather than on the information that could be obtained as a result of a medical procedure or treatment or benefits related to future health or function of the pet.

Decision making is an inherent aspect of medical encounters. For example, a study¹¹ of 81 appointments involving 41 primary care physicians and their patients found that each visit included at least 1 clinical decision, with an average of 3.20 clinical decisions/appointment (range, 1 to 8). Because most veterinary clients pay for their pet's care out-of-pocket, veterinarians and clients typically must factor financial costs into clinical decision making, and client understanding about costs associated with his or her pet's health care is considered an essential component of good decision making in veterinary practice.¹² Including a discussion of cost along with any discussion of the clinical benefits of a particular treatment or procedure allows clients to make decisions that are both clinically and financially relevant.¹³

In the present study, the prevalence of cost discussions varied depending on the specific reason for which a decision was required, with cost discussions being least frequent during appointments requiring a decision regarding vaccination. Vaccination and, more recently, heartworm testing and medication have historically been the basis for a substantial proportion of clinical appointments in companion animal practice. Thus, it was not surprising that these were among the treatments and procedures that received the least amount of cost discussion. However, veterinarians need to remain conscious that although experienced pet owners may require less discussion about routine costs, pet owners with less experience are often interested in discussing the costs of routine veterinary care.⁵ Importantly, a study¹⁴ exploring the relationship between owners and their pets found that approximately 1 in 8 current pet owners had little or no previous experience caring for a pet.

Although discussions of cost in general were relatively infrequent in the present study, appointments that included a decision regarding diagnostic testing or dentistry more often included a cost discussion than did appointments that included a decision regarding other areas of veterinary care. It was not apparent from our study why decisions relating to diagnostic testing or dentistry were more likely to involve cost discussions or why decisions relating to diet were likely to receive little discussion of cost. However, an American Animal Hospital Association study³ of compliance in small animal practice found that the rate of compliance in relation to diagnostic testing and dentistry is substantially higher than the rate of compliance for therapeutic veterinary diets. It has been proposed that poor client compliance in veterinary medicine is the result of a disconnect in communication between veterinarians' recommendations for the best possible care and clients' understanding of how their money and effort will benefit their pet.¹² Discussions of cost may help mitigate cost-related noncompliance, but empirical evidence for an association between cost discussions and client compliance is currently lacking in veterinary medicine.

An important finding in the present study was that during 38 of the 58 (66%) appointments with legitimate discussions of cost, discussions focused on cost in relation to the veterinarian's time or the services provided by the veterinarian. In contrast, only 10 (17%) of these appointments included discussions of cost related to future health or function of the pet. Findings in a previous study⁵ indicate that veterinarians and clients approach cost discussions from different perspectives, with veterinarians focused on tangibles such as time and services rendered whereas pet owners were interested in understanding how the costs contributed to the health and well-being of their pet. Klingborg and Klingborg¹² have recommended that veterinarians focus their conversations regarding veterinary fees on benefits to the animal, rather than emphasizing veterinary services, facilities, and equipment, and suggested that discussing fees was different from discussing the expense of providing veterinary care.

Surprisingly, reference to a written estimate was made during only 28 of the 200 (14%) appointments analyzed in the present study and in only 20 of the 58 (34%) appointments that contained a legitimate cost discussion. We believe that written estimates can be an effective means of facilitating cost discussions and therefore recommend that veterinarians consider using them more often. However, some veterinarians can find providing an estimate to clients to be a challenge.⁵ It is important to recognize that a written estimate is only an aid and that the cost discussion must proceed in a way that is relevant to the client while keeping the client informed and involved as diagnostic and treatment plans evolve and estimated or actual costs change.

A potential drawback of discussing costs with every veterinary client is that these discussions have the potential to add time to each appointment. Appointments in the current study that included a cost discussion were significantly longer than appointments that did not. It is possible that appointments that included a cost discussion were longer because they were more involved in terms of decision making and information exchange. However, logically it seems that, for any appointment, adding a discussion of cost without removing some other component of the veterinarian-client-patient interaction would increase appointment time. In the present study, veterinarians who scheduled appointments every 30 minutes, rather than every 15 minutes, were more likely to include a discussion of cost. Although scheduling additional time does not guarantee that a cost discussion will occur, longer appointments provide more time for such discussions to occur. In human medicine, the most common barrier reported by physicians to discussing out-of-pocket costs with patients is insufficient time.¹⁵ However, it has also been found in human medicine that training in appropriate communication skills often results in saved time,^16,17 and the same is likely true in veterinary medicine. Regardless, improving discussions of cost should result in fewer cost-related conflicts, which may save the veterinarian and practice more time in the long run.

In the present study, the likelihood of a cost discussion increased for strictly small animal practitioners as the number of years in practice decreased. In recent years, there has been an increased focus on the business aspects of veterinary medicine, particularly in relation to companion animal practice,^1,18,19 including the development of curricula designed to increase veterinary students' business acumen.^20,21 Thus, it is possible that more recent graduates may have a greater awareness of the economics of veterinary practice and, as a result, would be more likely to engage in discussions of the cost of veterinary care with their clients. Regardless, all veterinarians should consider the way they approach the monetary aspects of veterinary care during veterinarian-client-patient interactions to ensure they are communicating the value of their time and services in a way that is relevant and meaningful to their clients. It has been found that some pet owners suspect that veterinarians may have a conflict of interest with regard to both recommending and charging for patient care.⁵ Addressing cost discussions in a manner that is relevant and important to each veterinary client will be important in diminishing these suspicions.

The present study was restricted to veterinarian-client-patient interactions taking place within an examination room, and the study did not account for cost discussions that occurred outside the examination room or with support staff. Some veterinary practices advocate that support staff, rather than practice veterinarians, discuss costs with clients. However, this approach isolates the cost discussion from the joint decision-making process involving the client and veterinarian. We believe that involving the veterinarian in cost discussions is important in helping clients put costs in the appropriate context. Delegating this responsibility to someone other than the veterinarian inhibits discussion of options and prognosis within the context of the cost, which may make it more difficult for clients to understand how their financial decisions contribute to the overall health and well-being of their pet.

Importantly, the present study included only a small number of primary care veterinarians and their clients from a limited region in a single Canadian province. Differences may exist in the prevalence and nature of cost discussions in other regions. The small number of veterinarians (n = 20) included in the study and the low prevalence of cost discussions limited our ability to conduct multivariate analyses of factors potentially associated with the occurrence of cost discussions. Future studies should consider including a larger sample of veterinarians. In addition, research studying veterinarian-client communication, particularly in relation to decision-making and cost discussions, would benefit from including a blend of quantitative and qualitative approaches so that greater detail concerning these complex processes could be obtained while still allowing investigators to generalize findings to a broader population of veterinarians and their clients.