Questions conclusions in study on managing urethral obstructions in cats

I read the report “A protocol for managing urethral obstruction in male cats without urethral catheterization,”¹ in the December 1, 2010, issue of JAVMA with interest. The conclusion that “[t]his low-cost protocol could serve as an alternative to euthanasia when financial constraints prevent more extensive treatment” seems compelling until one does the math.

I sat down and calculated two estimates on the basis of my clinic's current charges for services.

The first involved conventional treatment and included several charges that may not be included in all estimates (ie, hydropulsion and preobstruction and postobstruction clinicopathologic testing). If results of preobstruction testing are fairly normal, I may not repeat the testing after the obstruction is relieved. I take two radiographic views of the abdomen to check for uroliths, and urine samples are analyzed and submitted for bacterial culture and susceptibility testing. Cats are given fluids IV, and I charge intensive hospitalization fees for all animals receiving fluids IV. I also insert a urethral catheter that is connected to a sterile collection system. Cats are given buprenorphine twice daily. I typically leave the urethral catheter in place for 12 hours if results of clinicopathologic testing are good and for 24 hours if the patient has clinically important azotemia. I specifically used the worst-case scenario to calculate my estimate for conventional treatment and came up with $1,027.00.

I then calculated an estimate for the protocol outlined in the article: only one radiographic view of the abdomen, one injection of acepromazine and buprenorphine followed by oral administration of medication, and two injections of dexmedetomidine (one each day until urination). I included a charge for major hospitalization instead of the more expensive intensive hospitalization, a single charge for clinicopathologic testing instead of two, and charges for SC fluid administration and cystocentesis. However, the article states that the mean time to urination was 34.6 hours; therefore, I included charges for three days of SC fluid administration. The mean number of cystocentesis procedures was three, so charges for three procedures were included. Finally, I included charges for three days of board and hospitalization because the authors state they kept patients 24 hours after their initial voluntary urination. In total, the estimated charge for the protocol as described came to $842.00.

I can't qualify this as low cost. The difference between the two protocols is $185.00. In addition, the report does not address whether the authors analyzed urine samples from their patients or submitted urine samples for bacterial culture and susceptibility testing. The emphasis seemed to be on making the cat urinate and not on addressing the reason for the obstruction. It was assumed obstructions were all stress induced.

In conclusion, this protocol does seem to be able to relieve urinary obstructions in male cats, but can easily be as costly as the conventional method and is short on diagnostic testing and prevention.

Meredith McGrath, dvm

Animal Care Center of Floyd

Floyd, Va

The author responds:

Thank you for your thoughtful consideration of our manuscript. Your point regarding the comparative cost is reasonable, although the charges will likely vary for each clinic depending on fee schedules, especially with regard to cost of hospitalization and the charge for each treatment or procedure performed. To promote enrollment in our study, owners were charged a flat fee of $350 to cover the cost of medications and materials as well as fees for ward hospitalization (rather than admittance to the intensive care unit). Medications were administered and procedures were performed by study personnel and so were not individually charged. However, even when taking into account these additional charges, we currently quote an estimate of $500 to $600 for treatment using the published protocol. This is considerably less than our estimate for treatment with the standard approach (currently $1,500 to $2,000 in our clinic), which includes IV and urinary catheterization, monitoring in intensive care, and hospitalization for three to four days. The decision to use this protocol as an alternative to euthanasia will depend on the cost analysis for each clinic and the financial capabilities of the client.

You also make a valid point with regard to provision of additional diagnostic testing, such as urinalysis and bacterial culture and susceptibility testing of a urine sample. Given the low incidence of urinary tract infection associated with feline lower urinary tract disease in general (< 2% and 10% in two studies^1,2) and specifically in cats with urethral obstruction (0%),² the benefit of performing bacterial culture at the time of initial examination is questionable, especially when financial resources are limited. As such, we do not routinely perform bacterial culture in these cases, unless there has been previous recent (ie, within the past six months) urethral catheterization. In addition, the results of urinalysis do not typically affect case management or at-home recommendations for blocked cats in our hospital, so this is another test that is often omitted in a further effort to reduce costs. However, if performing these diagnostic tests is desired, they would need to be factored into the estimates for either treatment approach.

Edward Cooper, vmd, ms, dacvecc

Department of Veterinary

Clinical Sciences

College of Veterinary Medicine

The Ohio State University

Columbus, Ohio

Institutions working on pet loss counseling

The recent JAVMA news article,¹ “Addressing human needs,” focuses in part on the historical development of pet loss counseling at three veterinary medical institutions: the Animal Medical Center in New York City, the University of Tennessee, and the University of Illinois.

The article omits reference to similar counseling programs at Colorado State University and the University of Pennsylvania. These two institutions are, I believe, the mothers of pet loss support in veterinary medicine in that both of these institutions began to work with the human end of the human-animal bond in the early 1980s or earlier. In 1994, the Colorado State University College of Veterinary Medicine published the fine book, “The Human-Animal Bond and Grief,” by Laurel Lagoni, Carolyn Butler, and Suzanne Hetts.

Bruce Max Feldmann, dvm

Berkeley, Calif

More on the future of veterinary education

I applaud the letter¹ by Eric J. Fish, a student at Western University in California, regarding the draft and recommendations of the North American Veterinary Medical Education Consortium (NAVMEC).

The demand that new graduates have multispecies clinical expertise has been at odds with the needs of the veterinary practice marketplace for at least the past 40 years. It was part of the justification for adopting a core-elective program at the University of Pennsylvania in the early 1970s.

Although it is true that the responsibilities of the veterinary profession have continued to broaden, it makes no sense to prepare all graduates for all roles. Rather, the collective capabilities of graduates should reflect the needs of the marketplace, with individual graduates being able to focus their training and expertise on specific career tracks. If graduates later on wish to change career tracks, a retraining period would be appropriate.

The veterinary profession cannot ignore its responsibilities to society, but it also cannot continue to expect its new members to be prepared to do it all, particularly when few, if any, jobs have that expectation. The NAVMEC has a huge opportunity to lead the profession at a time of great challenge. This will not be achieved by perpetuating an outdated view of the veterinary practitioner and by ignoring major forces for change, such as globalization. I hope the NAVMEC carefully rethinks some of its recommendations before releasing its final report.

Hugh Lewis, bvms, dacvp

Vancouver, Wash